A  TREATISE 


ON 


THE  SCIENCE  AND  PRACTICE 


OF 


MIDWIFEKY. 


BY 

W.  S.  PLAYFAIR,  M.D.,  LL.D.,  F.R.C.P., 

PHYSICIAN-ACCOUCHEUR  TO  H.I.  AND  R.  H.  THE  DUCHESS  OF  EDINBURGH;    PROFESSOR    OF  OBSTETRIC 

MEDICINE  IN  KING'S  COLLEGE  ;  PHYSICIAN  FOR  THE  DISEASES  OF  WOMEN  AND    CHILDREN   TO 

KING'S    COLLEGE    HOSPITAL ;    CONSULTING    PHYSICIAN    TO    THE     GENERAL     LYING-IN 

HOSPITAL,  AND  TO  THE  EVELINA  HOSPITAL  FOR  CHILDREN  ;  LATE  PRESIDENT 

OF  THE  OBSTETRICAL  SOCIETY  OF  LONDON  ;  EXAMINER  IN  MIDWIFERY 

TO  THE  UNIVERSITIES  OF  CAMBRIDGE  AND  LONDON  AND  TO 

THE  ROYAL  COLLEGE  OF  PHYSICIANS 


SIXTH  AMERICAN  FROM  THE  EIGHTH  ENGLISH  EDITION. 

WITH  NOTES  AND  ADDITIONS 

BY  EGBERT  P.  HARRIS,  A.M.,  M.D., 

HONORARY  FELLOW  OF  THE  AMERICAN  GYNECOLOGICAL  SOCIETY,  AND  OF  THE  PHILADELPHIA 

OBSTETRICAL  SOCIETY ;   CORRESPONDING  MEMBER  OF  THE  OBSTETRICAL  SOCIETY  OF  LEIPZIG, 

AND  OF  THE  ROYAL  MEDICO-CHIRURGICAL  ACADEMY,  OF  NAPLES,  ETC. 

WITH   FIVE  PLATES  AND  TWO  HUNDRED  AND  SEVENTEEN  ILLUSTRATIONS. 


PHILADELPHIA: 

LEA  BROTHERS   &  CO. 

1893. 


1 0  '0 
Y  i-t  S 


Entered  according  to  the  Act  of  Congress,  in  the  year  1893,  by 

LEA    BROTHERS    &    CO., 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington.    All  rights  reserved. 


DOBNAN,    PRINTER, 
PHILADELPHIA. 


EDITOR'S  PREFACE  TO  SIXTH  AMERICAN  EDITION. 


DURING  the  intervening  four  years  since  the  last  American 
edition  was  issued,  very  decided  advances  have  been  made  in  the 
field  of  obstetric  surgery,  particularly  in  the  adoption  of  methods 
that  have  resulted  in  the  saving  of  human  life.  The  conservative 
Csesarean  operation  in  the  most  carefully  managed  European  mater- 
nities, and  even  in  the  general  practice  in  our  own  country,  may  be 
honestly  claimed  to  save  90  per  cent,  of  the  women — 16  having  died 
out  of  160  cases  in  certain  European  hospitals,  and  2  out  of  the 
last  20  in  the  United  States.  The  Porro-Csesarean  record  of  all 
countries  now  shows  a  mortality  which  has  been  reduced  to  14  per 
cent.,  as  proven  by  the  record  of  1890-1891 ;  and  the  sub-peritoneal, 
replacing  the  fatal  intra-peritoneal  method,  has  saved  22  women  out 
of  25.  The  introduction  of  symphyseotomy  into  our  country  a  year 
ago,  has  required  us  to  give  a  special  notice  to  this  operation,  now 
so  largely  performed  in  Europe,  and  attracting  a  growing  attention 
here,  because  of  its  possibilities  of  success.  The  term  laparotomy, 
and  the  prefix  laparo-,  as  applied  to  abdominal  surgery,  and  not  to 
flank-incisions,  have  been  abandoned  throughout  the  volume,  and 
the  term  codiotomy ,  and  the  prefix  ccelio-,  substituted  for  them. 
Craniotomy  having  fallen  in  the  estimation  of  American  obstetri- 
cians, and  some  of  the  younger  thinkers  of  Great  Britain,  because  of 
the  diminishing  dangers  of  Csesarean  and  symphyseotomic  deliveries, 
the  American  editor  has  striven  to  do  away  with  the  leaning  of  the 
English  author  toward  a  preference  for  the  infantile  destructive 
method,  begotten  of  opinions  based  upon  comparative  results  which 
were  prevalent,  and  thought  to  be  well  founded,  forty  years  ago. 
Notes  and  additions  of  the  American  editor  are  enclosed  in 
brackets  [  ]. 


329  SOUTH  TWELFTH  STREET,  PHILADELPHIA. 
September,  1893. 


(iii) 


AUTHOR'S  PREFACE  TO  THE  EIGHTH  EDITION. 


THE  large  edition  of  this  Treatise  which  was  published  in  the 
spring  of  1889  being  completely  exhausted,  the  author  has  subjected 
the  work  to  a  thorough  revision.  Since  1889  much  progress  has 
been  made  in  certain  departments  of  obstetrics  which  has  necessitated 
changes,  amounting  to  the  almost  complete  rewriting  of  some  of  the 
chapters,  as,  for  instance,  those  on  extra-uterine  pregnancy,  the 
Csesareau  section,  symphyseotomy,  and  puerperal  septicaemia.  Sev- 
eral new  illustrations  have  also  been  added.  He  trusts  that  these 
alterations  may  make  the  present  edition  a  satisfactory  guide  to  the 
most  .recent  advances  in  obstetric  medicine,  and  secure  for  it  the 
same  favorable  reception  which  the  profession  has  given  to  its 
predecessors,  for  which  he  feels  very  grateful.  He  has  to  express  his 
thanks  for  many  letters  he  has  received  from  students  of  medicine, 
in  all  parts  of  the  country,  containing  criticisms  and  suggestions, 
which  all  show  how  carefully  the  book  had  been  studied,  and  some  of 
which  he  has  adopted,  amongst  them  the  addition  of  a  separate  index 
to  the  first  volume.  He  has  also  to  express  his  obligations  to  his 
friend  and  colleague  Dr.  John  Phillips,  who,  it  is  to  be  feared  at 
much  inconvenience  to  himself,  has  again  carefully  revised  the  proof- 
sheets,  and  also  to  his  cousin,  Dr.  Hugh  Playfair,  for  assistance 
in  the  same  tedious  task. 

31  GEORGE  STREET,  HANOVER  SQUARE,  W. 
March,  1893. 


(V) 


AUTHOR'S  PREFACE  TO  THE  FIRST  EDITION. 


THOSE  who  have  studied  the  progress  of  Midwifery  know  that 
there  is  no  department  of  medicine  in  which  more  has  been  done  of 
late  years,  and  none  in  which  modern  views  of  practice  differ  more 
widely  from  those  prevalent  only  a  short  time  ago.  The  Author's 
object  has  been  to  place  in  the  hands  of  his  readers  an  epitome  of 
the  science  and  practice  of  midwifery  which  embodies  all  recent 
advances.  He  is  aware  that  on  certain  important  points  he  has 
recommended  practice  which  not  long  ago  would  have  been  consid- 
ered heterodox  in  the  extreme,  and  which,  even  now,  will  not  meet 
with  general  approval.  He  has,  however,  the  satisfaction  of  know- 
ing that  he  has  only  done  so  after  very  deliberate  reflection,  and 
with  the  profound  conviction  that  such  changes  are  right,  and  that 
they  will  stand  the  test  of  experience.  He  has  endeavored  to  dwell 
especially  on  the  practical  part  of  the  subject,  so  as  to  make  the  work 
a  useful  guide  in  this  most  anxious  and  most  responsible  branch  of 
the  profession.  It  is  admitted  by  all,  that  emergencies  and  difficul- 
ties arise  more  often  in  this  than  in  any  other  branch  of  practice ; 
and  there  is  no  part  of  the  practitioner's  work  which  requires  more 
thorough  knowledge  or  greater  experience.  It  is,  moreover,  a  lamen- 
table fact  that  students  generally  leave  their  schools  more  ignorant  of 
obstetrics  than  of  any  other  subject.  So  long  as  the  absurd  regula- 
tions exist  which  oblige  the  lecturer  on  midwifery  to  attempt  the 
impossible  task  of  teaching  obstetrics  in  a  short  three  months'  course 
— an  absurdity  which  has  over  and  over  again  been  pointed  out — 
such  must  of  necessity  be  the  case.  This  must  be  the  Author's 
excuse  for  dwelling  on  many  topics  at  greater  length  than  some  will 
doubtless  think  their  importance  merits,  since  he  desires  to  place  in 
the  hands  of  his  students  a  work  which  may  in  some  measure  supply 
the  inevitable  defects  of  his  lectures. 

(vii) 


viii  A.UTHOR'S  PREFACE  TO  FIRST  EDITION. 

Many  of  the  illustrations  are  copied  from  previous  authors,  while 
some  are  original.  The  following  quotation  from  the  preface  to 
Tyler  Smith's  Manual  of  Obstetrics  will  explain  why  the  source 
of  the  copied  woodcuts  has  not  been  in  each  instance  acknowledged : 
"When  I  began  to  publish,  I  determined  to  give  the  authority  for 
every  woodcut  copied  from  other  works.  I  soon  found,  however, 
that  obstetric  authors  of  all  countries,  from  the  time  of  Mauriceau 
downward,  had  copied  each  other  so  freely  without  acknowledgment 
as  to  render  it  difficult  or  impossible  to  trace  the  originals." 

The  Author  has  to  express  his  acknowledgments  to  many  friends 
for  their  kind  assistance  by  the  loan  of  illustrations  and  otherwise, 
and  more  especially  to  his  colleague,  Dr.  Hayes,  for  his  valuable 
aid  in  passing  the  work  through  the  press. 

31  GEORGE  STREET,  HANOVER  SQUARE. 
March,  187C. 


CONTENTS. 


PART  I. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  ORGANS  CONCERNED 
IN  PARTURITION 


CHAPTER  I. 

ANATOMY  OF  THE  PELVIS. 

PAGE 

Its  importance — Formation  of  pelvis — The  os  iunominatum  ;  its  three  divisions 
— Separation  between  the  true  and  false  pelvis — The  sacrum  and  coccyx — 
Mechanical  relations  of  the  sacrum — Pelvic  articulations  and  ligaments — 
Movements  of  the  pelvic  joints — The  pelvis  as  a  whole — Differences  in  the 
two  sexes — Measurements  of  the  pelvis — Its  diameters,  planes,  and  axes — 
Development  of  the  pelvis — Soft  parts  in  connection  with  the  pelvis  .  .  33 

CHAPTER  II. 

THE  FEMALE  GENERATIVE  ORGANS. 

Division  according  to  function :  1.  External  or  copulative ;  2.  Internal  or  for- 
mative organs — Mons  Veneris — Labia  majora  and  minora — The  clitoris — 
The  vestibule  and  orifice  of  the  urethra — Passing  of  the  female  catheter — 
Orifice  of  vagina — The  hymen — Carunculse  myrtiformes — The  glands  of 
the  vulva — The  perineum— The  vagina— The  uterus :  its  position  and 
anatomy — [Partitioned  uterus] — The  ligaments  of  the  uterus— The  paro- 
varium — The  Fallopian  tubes — The  ovaries — The  Graafian  follicles  and 
the  ova — The  mammary  glands  .  . 49 

CHAPTER  III. 

OVULATION   AND  MENSTRUATION. 

Functions  of  the  ovary — Changes  in  the  Graafian  follicle:  1.  Maturation;  2. 
Escape  of  the  ovum  —  Formation  of  the  corpus  luteum — [Precocious 
physical  womanhood] — Quality  and  source  of  the  menstrual  blood — Theory 
of  menstruation — Purpose  of  the  menstrual  loss — Vicarious  menstruation 

— Cessation  of  menstruation •        .82 

(ix) 


CONTENTS. 

PART  II. 

PREGNANCY. 


CHAPTER  I. 

CONCEPTION   AND  GENERATION. 

PAGE 

The  semen— Site  and  mode  of  impregnation — Changes  in  the  ovum — Cleavage 
of  the  yelk — The  decidua  and  its  formation — Formation  of  the  amnion — 
The  umbilical  vesicle  and  allantois — The  liquor  amnii  and  its  uses — The 
.     chorion — The  placenta ;  its  formation,  anatomy,  and  functions   ...      96 

CHAPTER  II. 

THE  ANATOMY  AND  PHYSIOLOGY   OP  THE   FCETUS. 

Appearance  of  the  foetus  at  various  stages  of  development — [Very  small  foetuses 
habitually  produced  by  some  mothers] — Anatomy  of  the  foetal  head: — The 
sutures  and  fontanelles — Influence  of  sex  and  race  on  the  foetal  head — 
Position  of  the  foetus  in  utero — Functions  of  the  foetus — The  foetal  circu- 
lation   122 

CHAPTER  III. 

PREGNANCY. 

Changes  in  the  form  and  dimensions  of  the  uterus — Changes  in  the  cervix — 
Changes  in  the  texture  of  the  uterine  tissues,  the  peritoneal,  muscular,  and 
mucous  coats — General  modifications  in  the  body  produced  by  pregnancy  .  137 

CHAPTER  IV. 

SIGNS  AND  SYMPTOMS  OF   PREGNANCY. 

Signs  of  a  fruitful  conception — Cessation  of  menstruation — Sympathetic  disturb- 
ances— Morning  sickness,  etc. — Mammary  changes — Enlargement  of  the 
abdomen — Quickening — Intermittent  uterine  contractions — Vaginal  signs 
of  pregnancy — Ballottement,  etc. — Auscultatory  signs  of  pregnancy — Foetal 
pulsations — Uterine  souffle,  etc 149 

CHAPTER  V. 

THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY — SPURIOUS  PREGNANCY — 
THE  DURATION   OF  PREGNANCY — SIGNS   OF   RECENT  PREGNANCY. 

Adipose  enlargement  of  the  abdomen — Distention  of  the  uterus  by  retained 
menses,  etc. — Congestive  enlargement  of  uterus — Ascites — Uterine  and 
ovarian  tumors — Spurious  pregnancy ;  its  causes,  symptoms,  and  diagnosis 
— The  duration  of  pregnancy — Sources  of  fallacy — Methods  of  predicting 
the  date  of  delivery — Protraction  of  pregnancy — Signs  of  recent  delivery  .  164 


CONTENTS. 


CHAPTER  VI. 

ABNORMAL    PREGNANCY,    INCLUDING    MULTIPLE    PREGNANCY,    SUPER- 
FCETATION,   EXTRA-UTERINE  FCETATION,   AND   MISSED   LABOR. 

PAGB 

Plural  births ;  their  frequency,  relative  frequency  in  different  countries,  causes, 
etc- — Super-fcetation  and  super-fecundation — Nature — Explanation — Objec- 
tions to  admission  of  such  cases — Their  possibility  admitted — Extra-uterine 
pregnancy — Classification — Causes — Tubal  pregnancies — Changes  in  the 
Fallopian  tubes — Condition  of  uterus — Progress  and  termination — Diag- 
nosis— Treatment — Abdominal  pregnancy  ;  description,  diagnosis,  treat- 
ment— Missed  labor;  its  symptoms,  causes,  and  treatment— [Causes  of 
missed  labor] 173 


CHAPTER  VII. 

DISEASES  OF  PREGNANCY. 

Some  only  sympathetic,  others  mechanical  or  complex  in  their  origin — De- 
rangement of  the  digestive  organs;  excessive  nausea  and  vomiting, 
diarrhoea,  constipation,  hemorrhoids,  ptyalism,  dyspnoea,  etc. — Palpitation 
— Syncope — Anaemia  and  chlorosis — Albuminuria 203 

CHAPTER  VIII. 

DISEASES  OF  PREGNANCY  (continued). 

Disorders  of  the  nervous  system ;  insomnia,  headaches  and  neuralgia,  paralysis 
— Chorea;  disorders  of  the  urinary  organs;  retention  of  urine,  irritability 
of  the  bladder,  incontinence  of  urine,  phosphatic  deposits — Leucorrhcea — 
Effects  of  pressure — Laceration  of  veins — Displacements  of  the  gravid 
uterus;  prolapse,  anteversion,  retroversion  —  Diseases  coexisting  with 
pregnancy ;  eruptive  fevers,  smallpox,  measles,  scarlet  fever,  continued 
fever,  phthisis,  cardiac  disease,  syphilis,  icterus,  carcinoma — Pregnancy 
complicated  with  ovarian  and  fibroid  tumors  .  •  .  .  .  217 

CHAPTER  IX. 

PATHOLOGY   OF   THE   DECIDUA   AND   OVUM. 

Pathology  of  the  decidua  —  Hydrorrhcea  gravidarum — Pathology  of  the 
chorion ;  vesicular  degeneration,  myxoma  fibrosum — Pathology  of  the 
placenta ;  blood  extravasations,  fatty  degeneration,  etc. — Pathology  of  the 
amnion — [Hydramnios] — Deficiency  of  liquor  amnii,  etc — Pathology  of 
of  the  umbilical  cord —Pathology  of  the  foetus;  blood  diseases  transmitted 
through  the  mother:  smallpox,  measles,  and  scarlet  fever,  intermittent 
fevers,  lead-poisoning,  syphilis — Inflammatory  diseases — Dropsies — Tumors 
— Wounds  and  injuries  of  the  f<ctus—  Intra-uterine  amputations — [Arrested 
pullulation] — Death  of  the  foetus 234 


xji  CONTENTS. 

CHAPTER  X. 

ABORTION   AND   PREMATURE   LABOR. 

PAGE 

Importance  and  frequency— Definition  and  classification— Frequency— Recur- 
rence—Causes— Causes  referable  to  fetus— Changes  in  a  dead  ovum  re- 
tained in  utero — Extravasations  of  blood— Moles,  etc. — Causes  depending 
on  maternal  state,  syphilis— Causes  acting  through  nervous  sytem,  physical 
causes,  etc.— Causes  depending  on  morbid  states  of  uterus— Symptoms- 
Preventive  treatment— Prophylactic  treatment — Treatment  when  abortion 
is  inevitable— After-treatment 252 


PART  III. 

LABOR. 


CHAPTER  I. 

THE  PHENOMENA   OF   LABOR. 

Causes  of  labor — Mode  in  which  the  expulsion  of  the  child  is  effected — The 
uterine  contraction — Mode  in  which  the  dilatation  of  the  cervix  is  effected — 
Rupture  of  the  membranes — Character  and  source  of  pains  during  labor — 
Effects  of  pains  on  mother  and  foetus— Division  of  labor  into  stages — Pre- 
paratory stage— False  pains— First  stage— Second  stage— Third  stage — 
Mode  in  which  the  placenta  is  expelled — Duration  of  labor  .  .  .  265 

CHAPTER  II. 

MECHANISM  OF   DELIVERY   IN   HEAD   PRESENTATIONS. 

Importance  of  subject— Frequency  of  head  presentations — The  different  posi- 
tions of  the  head — First  position — Division  of  mechanical  movements  into 
stages —Flexion — Descent  and  levelling  movement — Rotation — Exten>ion 
— External  rotation — Second  position — Third  position —Fourth  position — ' 
Caput  succedaneum — Alteration  in  shape  of  head  from  moulding  .  ..  278 

CHAPTER  III. 

MANAGEMENT  OF  NATURAL  LABOR. 

Preparatory  treatment — Dress  of  patient  during  pregnancy — The  obstetric  bag 
— Duties  on  first  visiting  patient — Antiseptic  precautions — False  pains — 
[Kelly's  rubber  protector  in  parturient  cases] — Their  character  and  treat- 
ment—Vaginal examination — The  position  of  patient — Artificial  rupture 
of  membranes — Treatment  of  propulsive  stage — Relaxation  of  the  peri- 
neum— Treatment  of  lacerations — Expulsion  of  child — Promotion  of 
uterine  contraction — Ligature  of  the  cord — Management  of  the  third  stage 
of  labor — [Expulsion  of  placenta] —Application  of  the  binder — After- 
treatment ,  290 


CONTENTS.  xiii 

CHAPTER  IV. 

ANAESTHESIA   IN   LABOR. 

PAGE 

Agents  employed — Chloral :  its  object  and  mode  of  administration — Ether — 
Chloroform;  its  use,  objections  to,  and  mode  of  administration — [Ether 
safer  than  chloroform]  .  308 

CHAPTER  V. 

PELVIC   PRESENTATIONS. 

Frequency — Causes — Prognosis  to  mother  and  child — Diagnosis  by  abdominal 
palpation  and  by  vaginal  examination — [Bimanual  version  in  breech  cases] 
— Differential  diagnosis  of  breech,  knee,  and  foot — Mechanism — Treatment 
— Management  of  impacted  breech  presentations — [Breech  forceps]  .  .  312 

CHAPTER  VI. 

PRESENTATIONS  OF   THE  FACE. 

Erroneous  views  formerly  held  on  the  subject — Frequency — Mode  of  production 
— Diagnosis — Mechanism — Four  positions  of  the  face— Description  of  de- 
livery in  first  face  position — Mento-posterior  position  in  which  rotation 
does  not  take  place — Prognosis — Treatment — Brow  presentation  .  .  323 

CHAPTER  VII. 

DIFFICULT   OCCIPITO-POSTERIOR  POSITIONS. 

Causes  of  face-to-pubes  delivery — Mode  of  treatment — Upward  pressure  on 
forehead — Downward  traction  on  occiput — Use  of  forceps — Peculiarities 
of  forceps  delivery — [Version  by  the  vertex] — [Use  of  the  hand  in  occipito- 
posterior  positions] 333 

CHAPTER  VIII. 

PRESENTATIONS  OF  SHOULDER,  ARM,  OR  TRUNK — COMPLEX  PRESENTATIONS 
— PROLAPSE  OF  THE  FU.NIS. 

Position  of  the  foetus — Division  into  dorso-anterior  and  dorso  posterior  posi- 
tions— Causes —Prognosis  and  frequency — Diagnosis — Mode  of  distinguish- 
ing position  of  child — Differential  diagnosis  of  shoulder,  elbow,  and  hand 
—Mechanism — The  two  possible  modes  of  delivery  by  the  natural  powers 
— Spontaneous  version — Spontaneous  evolution — Treatment — [Caesarean 
operation  for  foetal  impaction] — Complex  presentation :  foot  or  hand  with 
head ;  hand  and  feet  together — Dorsal  displacement  of  the  arm — Prolapse 
of  the  umbilical  cord — Frequency — Prognosis — Causes— Diagnosis — Postu- 
ral treatment — Artificial  reposition — Treatment  when  reposition  fails  .  336 


xiy  CONTENTS. 

CHAPTER  IX. 

PKOLONGED   AND   PRECIPITATE   LABORS. 


PAGE 


Evil  effects  of  prolonged  labor— Influence  of  the  stage  of  labor  in  protraction- 
Delay  in  the  first  stage  rarely  serious— Temporary  cessation  of  pains— 
Symptoms  of  protraction  in  the  second  stage— State  of  the  uterus  in  pro- 
tracted labor — Cases  of  protraction  due  to  morbid  condition  of  the  expul- 
sive powers  —  Causes  of  protraction — Treatment — Oxytocic  remedies- 
Ergot  of  rye,  etc.  —  Manual  pressure  —  Instrumental  delivery  (case  of 
Princess  Charlotte  of  Wales)— Precipitate  labor— Its  causes  and  treatment 
—[Rapid  delivery] 351 

CHAPTER  X. 

LABOR   OBSTRUCTED   BY   FAULTY   CONDITION   OF   THE   SOFT   PARTS. 

Rigidity  of  the  cervix :  its  causes,  effects,  and  treatment— [Csesarean  section  in 
cancer  of  the  cervix] — Ante-partum  hour-glass  contraction — Bands  and 
cicatrices  in  the  vagina — Extreme  rigidity  of  the  perineum— Labor  com- 
plicated with  tumor  —  [Csesarean  results  in  tumor  cases]  — Vaginal  cystocele 
—Calculus— Hernial  protrusions — [Impaction  of  bowels  from  eating  clay] — 
(Edema  of  vulva— Haematic  effusions,  etc.— [Polypus  obstructing  delivery]  366 

CHAPTER  XI. 

DIFFICULT   LABOR   DEPENDING   ON   SOME   UNUSUAL   CONDITION   OF   THE 

FCETUS. 

Plural  births,  treatment  of — Locked  twins— Conjoined  twins — Intra-uterine 
hydrocephalus:  its  dangers,  diagnosis,  and  treatment — Other  dropsical 
effusions— Foetal  tumors— Excessive  development  of  foetus  .  .  .  379 

CHAPTER  XII. 

DEFORMITIES   OF   THE   PELVIS. 

Classification — Causes  of  pelvic  deformity — [Rickets  and  osteomalacia] — The 
equally  enlarged  pelvis — The  equally  contracted  pelvis — The  undeveloped 
pelvis — [External  characteristics  of  a  large  and  tall  woman] — Masculine  or 
funnel-shaped  pelvis — Contraction  of  conjugate  diameter  of  brim — Scolio- 
rhachitic  pelvis — Figure-of-eight  deformity — Spondylolisthesis — [True 
character  of  spondylolisthetic  deformity] — Spondylolizema — Narrowing 
of  the  oblique  diameters — Obliquely  contracted  pelvis — [Coxalgic  deformity 
of  pelvis] — Kyphotic  pelvis — Robert's  pelvis — Deformity  from  old-stand- 
ing hip-joint  disease — Deformity  from  tumors,  fractures,  etc. — Effects  of 
contracted  pelvis  on  labor — Risks  to  the  mother  and  child — [Pelvic  exos- 
toses  obstructing  delivery]— Mechanism  of  delivery  in  head  presentation'; 
a,  in  contracted  brim;  b,  in  generally  contracted  pelvis— Diagnosis— Ex- 
ternal measurements — Internal  measurements — Mode  of  estimating  the 
conjugate  diameter  of  the  brim— Mode  of  diagnosticating  the  oblique  pelvis 
—Treatment — The  forceps— Turning — Craniotomy — [Symphyseotomy] — 
The  induction  of  premature  labor— Induction  of  abortion— [Dangers  of 
Caesarean  section  overestimated] ,  391 


CONTENTS.  XV 

CHAPTER  XIII. 

HEMORRHAGE   BEFORE   DELIVERY — PLACENTA   PRJEVIA. 

PAGE 

Definition — Causes — Symptoms — Sources  and  causes  of  hemorrhage — Prognosis 
— Treatment — [Braxton  Hicks's  bimanual  method  of  turning  in  placenta 
praevia] 418 

CHAPTER  XIV. 

HEMORRHAGE  FROM  SEPARATION   OF   A   NORMALLY  SITUATED   PLACENTA. 

Causes  and  pathology — Symptoms  and  diagnosis — Prognosis — Treatment          .    430 

CHAPTER  XV. 

HEMORRHAGE   AFTER   DELIVERY. 

Its  frequency — Generally  a  preventable  accident — Causes — Nature's  method  of 
controlling  hemorrhage — Uterine  contraction  — Thrombosis — Secondary 
causes  of  hemorrhage — Irregular  uterine  contraction — Placental  adhesions 
— Constitutional  predisposition  to  flooding — Symptoms — Preventive  treat- 
ment— Curative  treatment — Secondary  treatment — [Head  lowered  and 
body  elevated  in  fainting  from  hemorrhage] — Secondary  post-partum 
hemorrhage — Its  causes  and  treatment 433 

CHAPTER  XVI. 

RUPTURE   OF  THE  UTERUS,  ETC. 

Its  fatality — Seat  of  rupture — Causes,  predisposing  and  exciting — Symptoms — 
Prognosis — Treatment :  when  the  foetus  remains  in  utero  ;  when  the  foetus 
has  escaped  from  the  uterus — [Supra-vaginal  hysterectomy  no  right  or  title 
to  name  of  Porro] — Lacerations  of  the  cervix — Recapitulation — Lacerations 
of  the  vagina — Vesico-  and  recto-vaginal  fistulse — Their  mode  of  formation 
— Treatment — [Rational  treatment  of  rupture  of  uterus]  ....  451 

CHAPTER  XVII. 

INVERSION   OF   THE   UTERUS. 

Division  into  acute  and  chronic  forms — Description — Symptoms — Diagnosis — 
Mode  of  production — Treatment — [Spontaneous  reposition  of  the  inverted 
uterus  .  462 


xvi  CONTENTS. 

PART  IY. 

OBSTETRIC  OPERATIONS. 


CHAPTER  I. 

INDUCTION   OF   PREMATURE   LABOR. 


PAGE 


History— Objects — May  be  performed  on  account  of  either  the  mother  or  child 
— Modes  of  inducing  labor— Puncture  of  membranes— Administration  of 
oxytocics— Means  acting  indirectly  on  the  uterus— Dilatation  of  cervix — 
Separation  of  membranes — Vaginal  and  uterine  douches — Introduction  of 
flexible  catheter— [Infantile  mortality  after  induction  of  premature  labor] — 
Rearing  of  the  child 469 


CHAPTER  II. 

TURNING. 

History — Turning  by  external  manipulation — Object  and  nature  of  the  opera- 
tion—Cases suitable  for  the  operation— Statistics  and  dangers — Method  of 
performance — Cephalic  version — Method  of  performance — Podalic  version 
— Position  of  patient— Administration  of  anaesthetics — Period  when  the 
operation  should  be  undertaken —Choice  of  hand  to  be  used — Turning  by 
bi-polar  method — Turning  when  the  hand  is  introduced  into  the  uterus — 
Turning  in  abdomino-anterior  positions  — Difficult  cases  of  arm  presentation  479 

CHAPTER  III. 

THE   FORCEPS. 

Frequent  use  of  the  forceps  in  modern  practice — Description  of  the  instrument 
— The  short  forceps — Its  varieties — The  long  forceps — Suitable  to  all  cases 
alike — Action  of  the  instrument — Its  power  as  a  tractor,  lever,  and  com- 
pressor— Preliminary  considerations  before  operation — Use  of  anaesthetics 
— Description  of  the  operation — Low  forceps  operation — High  forceps 
operation — Possible  dangers  of  forceps  delivery — Possible  risks  to  the 
child— [The  forceps  in  America] 494 

CHAPTER   IV. 

THE   VECTIS — THE    FILLET. 

Nature  of  the  vectis — Its  use  as  a  lever  or  tractor — Cases  in  which  it  is  appli- 
cable -  Its  use  as  a  rectifier  of  malpositions — The  fillet — Nature  of  the 
instrument— Objection  to  its  use 519 


CONTENTS. 
CHAPTER  V. 

OPERATIONS   INVOLVING   DESTRUCTION   OP  THE  FCETUS. 

PA9B 

Their  antiquity  and  history  —  Division  of  subject  —  Nature  of  instruments 
employed  —  Perforator  —  Crochet  —  Craniotomy  forceps  —  Cephalotribe  — 
Forceps-saw  —  Ecraseur  —  Basilyst  —  Cases  requiring  craniotomy  —  Method 
of  Perforation  —  Extraction  of  the  head  —  Comparative  merits  of  cephalo- 
tripsy  and  craniotomy  —  Extraction  by  the  craniotomy  forceps  —  Extrac- 
tion of  the  body  —  [Meigs's  craniotomy  forceps]  —  Embryotomy  —  Decapita- 
tion and  evisceration  ...........  521 

CHAPTER  VI. 

• 

THE  C^SAREAN  SECTION  —  PORRO'S   OPERATION. 

History  of  the  operation  —  [Horn-rip  —  Macduff's  delivery]  —  Statistics  —  [Old 
Csesarean  records  of  little  practical  value  now  —  Csesarean  section  in 
America]  —  Results  to  mother  and  child—  Cases  requiring  operation  — 
[Csesarean  section  under  relative  indications]  —  Post-mortem  Csesarean  sec- 
tion —  Causes  of  death  after  Csesarean  section  —  Preliminary  preparations  — 
Description  of  the  operation  —  Subsequent  management  —  Porro's  operation 
—  [Csesarean  section  of  1893]  —  Substitutes  for  the  Csesarean  section  .  .  537 


CHAPTER  VII. 

COZLIO-ELYTROTOMY  —  SYMPHYSEOTOMY. 

History  —  Nature  of  the  operation  —  Advantages  over  the  Csesarean  section  — 
Cases  suitable  for  the  operation  —  Anatomy  of  the  parts  concerned  in  the 
operation  —  Method  of  performance  —  Subsequent  treatment  —  Symphyse- 
otomy  —  History  —  Its  recent  reintroduction  into  practice  —  Method  of  per- 
formance —  [Harris's  symphyseotomy  bistoury  —  Progress  and  results  of 
symphyseotomy  —  Statistics  —  Operation  after  induced  labor  —  Unilateral 
ischio-pubiotomy]  ...........  553 


CHAPTER  VIII. 

THE   TRANSFUSION   OF   BLOOD. 

History — Nature  and  object  of  the  operation — Use  of  blood  taken  from  the 
lower  animals — Difficulties  from  coagulation  of  fibrin — Modes  of  obviat- 
ing them — Immediate  transfusion — Addition  of  chemical  agents  to  prevent 
coagulation — Defibrination  of  the  blood — Statistical  results — Possible  dan- 
gers of  the  operation — Cases  suitable  for  transfusion — Description  of  the 
operation — Schafer's  directions  for  immediate  transfusion — Effects  of  suc- 
cessful transfusion — Secondary  effects  of  transfusion — [Transfusion  with 
defibrinated  blood] 564 


xviii  CONTENTS. 

PART  Y. 

THE  PUERPERAL  STATE. 


CHAPTER  I. 

THE  PUERPERAL   STATE   AND   ITS   MANAGEMENT. 

PAGE 

Importance  of  studying  the  puerperal  state— The  mortality  of  childbirth- 
Alterations  in  the  blood  after  delivery— Condition  after  delivery — Nervous 
shock— Fall  of  the  pulse— The  secretions  and  excretions— Secretion  of 
milk — Changes  in  the  uterus  after  delivery— The  lochia— The  after-pains 
— Management  of  women  after  delivery — Treatment  of  severe  after-pains — 
Diet  and  regimen 575 

CHAPTER  II. 

MANAGEMENT  OP  THE  INFANT,   LACTATION,   ETC. 

Commencement  of  respiration  after  the  birth  of  the  child — Apparent  death  of 
the  newborn  child — Its  treatment — Washing  and  dressing  the  child — 
Application  of  the  child  to  the  breast — The  colostrum  and  its  properties — 
Secretion  of  milk — Importance  of  nursing — Selection  of  a  wet-nurse- 
Management  of  lactation — Diet  and  regimen  of  nursing  women — [Diet 
proper  for  wet-nurses] — Period  of  weaning — Disorders  of  lactation — Means 
of  arresting  the  secretion  of  milk — Defective  secretion  of  milk — [Milk  diet 
for  nursing  mothers] — Depressed  nipples — Fissures  and  excoriations  of  the 
nipples — Excessive  flow  of  milk — Mammary  abscess— Hand-feeding — 
Causes  of  mortality  in  hand-feeding — Various  kinds  of  milk — Method  of 
hand-feeding 586 

CHAPTER  III. 

PUERPERAL  ECLAMPSIA. 

Its  doubtful  etiology — Premonitory  symptoms — Symptoms  of  the  attack — Con- 
dition between  the  attacks-— Relation  of  the  attacks  to  labor — Results  to 
mother  and  child — Pathology — Treatment — Obstetric  management — [Urine 
to  be  examined  in  eclamptic  cases] 603 

CHAPTER  IV. 

PUERPERAL  INSANITY. 

Classification — Proportion  of  various  forms — Insanity  of  pregnancy — Predispos- 
ing causes — Period  of  pregnancy  at  which  it  occurs — Type  of  insanity — 
Prognosis — Transient  mania  during  delivery— Puerperal  insanity  (proper) 
—Type  of  insanity — Causes — Theory  of  its  dependence  on  a  morbid  state 
of  the  blood — Objections  to  the  theory — Prognosis — Post-mortem  signs — 
Duration — Insanity  of  lactation — Type —Symptoms — Of  mania — Of  melan- 
cholia— Treatment — Question  of  removal  to  asylum — Treatment  during 
convalescence  ...!..  .  612 


CONTENTS.  Xix 

CHAPTER  V. 

PUERPERAL   SEPTICAEMIA. 

PAGE 

Differences  of  opinion — Confusion  from  this  cause — Modern  view  of  this  disease 
— History — Its  mortality  in  lying-in  hospitals — Numerous  theories  as  to 
its  nature — Theory  of  local  origin — Theory  of  an  essential  zymotic  fever — 
Theory  of  its  identity  with  surgical  septicaemia — Nature  of  this  view — 
Channels  through  which  septic  matter  may  be  absorbed — Character  and 
origin  of  septic  matter  often  obscure — Division  into  autogenetic  and  hetero- 
genetic  cases — Objections  to  term  "autogenetic" — Sources  of  saprsemia — 
Sources  of  heterogenetic  infection — Influence  of  cadaveric  poison — Infec- 
tion from  erysipelas — Infection  from  other  zymotic  diseases — Infection 
from  sewer-gas — Cases  illustrating  this  mode  of  infection — Contagion  from 
other  puerperal  patients — Mode  in  which  the  poison  may  be  conveyed  to 
the  patient — Conduct  of  the  practitioner  in  relation  to  the  disease — Nature 
of  the  septic  poison — Local  changes  resulting  from  the  absorption  of  septic 
material  —  Channels  through  which  systemic  infection  is  produced — 
Pathological  phenomena  observed  after  general  blood-infection  —  Four 
principal  types  of  pathological  change — Intense  cases  without  marked 
post-mortem  signs— Cases  characterized  by  inflammation  of  the  serous 
membranes — Cases  characterized  by  the  impaction  of  infected  emboli,  and 
secondary  inflammation  and  abscess— Description  of  the  disease — Duration 
— Varieties  of  symptoms  in  different  cases — Symptoms  of  local  complica- 
tions— Treatment 623 

CHAPTER  VI. 

PUERPERAL  VENOUS  THROMBOSIS  AND  EMBOLISM. 

Puerperal  thrombosis  and  its  results — Conditions  which  favor  thrombosis — 
Conditions  which  favor  coagulation  in  the  puerperal  state — Distinction 
between  thrombosis  and  embolism — Is  primary  thrombosis  of  the  pulmo- 
nary arteries  possible  ? — History — Symptoms  of  pulmonary  obstruction — 
Is  recovery  possible? — Causes  of  death —Post-mortem  appearances — Treat- 
ment— Puerperal  pleuro-pneumonia :  its  causes  and  treatment  .  .  656 


CHAPTER  VII. 

PUERPERAL   ARTERIAL  THROMBOSIS   AND  EMBOLISM. 

Causes — Symptoms — Treatment 668 

CHAPTER  VIII. 

OTHER  CAUSES  OF  SUDDEN   DEATH   DURING  LABOR  AND  THE 
PUERPERAL   STATE. 

Organic  and  functional  causes— Idiopathic  asphyxia— Pulmonary  apoplexy — 
Cerebral  apoplexy— Syncope— Shock  and  exhaustion— Entrance  of  air  into 
the  veins 670 


XX  CONTENTS. 


CHAPTER  IX. 

PERIPHERAL  VENOUS  THROMBOSIS   (SYN. :    CRURAL  PHLEBITIS — PHLEGMAS1A 
DOLENS — ANASARCA  SEROSA — CEDEMA  LACTEUM — WHITE   LEG,   ETC  ) 

PAGE 

Nature — Symptoms — History  and  pathology — [Crural  phlebitis  after  Csesarean 
and  Porro  operations] — Anatomical  form  of  the  thrombi  in  the  veins — 
Detachment  of  emboli — Treatment 673 


CHAPTER  X. 

PELVIC  CELLULITIS  AND   PELVIC   PERITONITIS. 

Two  forms  of  inflammatory  disease  met  with  after  labor— Variety  of  nomen- 
clature— Importance  of  differential  diagnosis — Etiology — Connection  with 
septicaemia — Seat  of  inflammation — Relative  frequency  of  the  two  forms  of 
disease — Symptomatology — Results  of  physical  examination — Terminations 
— Prognosis — Treatment .  680 


INDEX 689 


PLATE    I. 


Os  Pnbis 


Bladder. 


Clitori 


Portio 
Yagiualis 


Vagina 


SKCTION  OF  A   FROZEN  BODY  IN  THE  LAST  MONTH  OF  PREGNANCY  (AFTER  BRAUNE),  ILLUSTRATING  THE 
RELATIONS  OF  THE  UTERUS  TO  THE  SURROUNDING  PARTS,   AND  THE  ATTITUDE  OF  THE 
FCETUS,  WHICH  IS  LYING  IN  THE  SECOND  CRANIAL  POSITION. 


PLATE    II. 


Pancreas 


Stomach 


Coeliac  A. 

Sup.  Mcscnt.A 
V.  Portie 


Ext.  Os  Uteri 


Rectum 


Liquor  Amnii 


SECTION  OF  A  FROZEN  BODY  AT  THE  TERMINATION  OF  THE  FIRST  STAGE  OF  LABOR  (AFTER  BRAUNE). 

THE  BAG  OF  MEMBRANES  IS  STILL  UNBROKEN,  THE  CERVIX  IS  FULLY  DILATED,  AND 

THE  HEAD  (IN  THE  SECOND  POSITION)  IS  IN  THE  PELVIC  CAVITY. 


THE  SCIENCE  AND  PRACTICE 


MIDWIFEKY. 


PART  I. 

ANATOMY  AND   PHYSIOLOGY  OF  THE  ORGANS   CONCERNED 

IN  PARTURITION. 


CHAPTER    I. 

ANATOMY  OF  THE  PELVIS. 

The  pelvis  is  the  bony  basin  situated  between  the  trunk  and  the 
lower  extremities.  To  the  obstetrician  its  study  is  of  paramount 
importance ;  for  it  not  only  contains,  in  the  unimpregnated  state,  all 
the  organs  connected  with  the  function  of  reproduction,  but  through 
its  cavity  the  foetus  has  to  pass  in  the  process  of  parturition.  An 
accurate  knowledge,  therefore,  of  its  anatomical  formation  may  be 
said  to  be  the  very  alphabet  of  obstetrics,  without  which  no  one  can 
practise  midwifery,  either  with  satisfaction  to  himself  or  safety  to  his 
patient. 

In  a  treatise  on  obstetrics,  however,  any  detailed  account  of  the 
purely  descriptive  anatomy  of  the  pelvis  would  be  out  of  place.  A 
knowledge  of  that  must  be  taken  for  granted,  and  it  is  only  necessary 
to  refer  to  those  points  which  have  a  more  or  less  direct  bearing  on 
the  study  of  its  obstetrical  relations. 

The  pelvis  is  formed  of  four  bones.  On  either  side  are  the  ossa  in- 
nominata,  joined  together  by  the  sawum  ;  to  the  inferior  extremity  of 
the  sacrum  is  attached  the  coccyx,  which  is,  in  fact,  its  continuation. 

The  os  innominatum  (Fig.  1)  is  an  irregularly  shaped  bone 
originally  formed  of  three  distinct  portions,  the  ilium,  the  ischium, 
and  the  pubes,  which  remain  separated  from  each  other  up  to  and 
beyond  the  period  of  puberty.  They  are  united  at  the  acetabultim  by 
a  Y-shaped  cartilaginous  junction,  which  does  not,  as  a  rule,  become 

3 


34  ORGANS    CONCERNED    IN    PARTURITION. 

ossified  until  about  the  twentieth  year.  The  consequence  is  that^the 
pelvis,  during  the  period  of  growth,  is  subject  to  the  action  of  various 
mechanical  influences  to  a  far  greater  extent  than  in  adult  life ;  and 
these,  as  we  shall  presently  see,  have  an  important  effect  in  deter- 
mining the  form  of  the  bones.  The  external  surface  and  borders  of 
the  os  inuominatum  are  chiefly  of  obstetric  interest  from  giving  attach- 
ment to  muscles,  many  of  which  have  an  important  accessory  influence 
on  parturition,  such  as  the  muscles  forming  the  abdominal  wall,  which 
are  attached  to  its  crest,  and  those  closing  its  outlet  and  forming  the 
perineum,  which  are  attached  to  the  tuberositv  of  the  ischiuin.  On 
the  anterior  and  posterior  extremities  of  the  crest  of  the  ilium  are 
two  prominences  (the  anterior  and  posterior  spinous  processes)  which 
are  points  from  which  certain  measurements  are  sometimes  taken. 
The  internal  surface  of  the  upper  fan-shaped  portion  of  the  os  innomi- 
naturn  gives  attachment  to  the  iliacus  muscle,  and  contributes  to  the 


FIG.  1. 


Os  innominatum. 

support  of  the  abdominal  contents ;  along  with  its  fellow  of  the  oppo- 
site side  it  forms  the  false  pelvis.  The  false  is  separated  from  the  true 
pelvis  by  the  ilio-pectineal  line,  which,  with  the  upper  margin  of  the 
sacrum,  forms  the  brim  of  the  pelvis.  This  is  of  special  obstetric 
importance,  as  it  is  the  first  part  of  the  pelvic  cavity  through  which 
the  child  passes,  and  that  in  which  osseous  deformities  are  most  often 
met  with.  At  one  portion  of  the  ilio-pectineal  line,'  corresponding 
with  the  junction  of  the  ilium  and  pubes,  is  situated  a  prominence, 
which  is  known  as  the  ilio-pectineal  eminence. 

The  internal  smooth  surface  of  the  innominate  bone  below  the 
linea  ilio-pectinea  forms  the  greater  portion  of  the  pelvis  proper.  In 
front,  with  the  corresponding  portions  of  the  opposite  bone,  it  forms 
the  arch  of  the  pubes,  under  which  the  head  of  the  child  passes  in 
labor. 

Behind  this  we  observe  the  oval  obturator  foramen,  and  below  that 
the  tuberosity  and  spine  of  the  ischium,  the  latter  separating  the  great 


ANATOMY    OF    THE    PELVIS. 


35 


FIG  2. 


and  lesser  sciatic  notches,  and  giving  attachment  to  ligaments  of 
importance.  The  rough  articulating  surface  posteriorly,  by  which  the 
junction  with  the  sacrum  is  effected,  may  be  noted,  and  above  this  the 
prominence  to  which  the  powerful  ligaments  joining  the  sacrum  and  os 
iunominatum  are  attached. 

The  sacrum  (Fig.  2)  is  a  triangular  and  somewhat  spongy  bone 
forming  the  continuation  of  the  spinal  column,  and  binding  together 
the  ossa  innominata.  It  is  originally 
composed  of  five  separate  portions,  anal- 
ogous to  the  vertebrae,  which  ossify  and 
unite  about  the  period  of  puberty,  leaving 
on  its  internal  surface  four  prominent 
ridges  at  the  points  of  junction.  The 
upper  of  these  is  sometimes  so  well 
marked  as  to  be  mistaken,  on  vaginal 
examination,  for  the  pjromontory  of  the 
sacrum  itself. 

The  base  of  the  sacrum  is  about  4^ 
inches  in  width,  and  its  sides  rapidly 
approximate  until  they  nearly  meet  at 
its  apex,  giving  the  whole  bone  a  trian- 
gular or  wedge  shape.  The  anterior  and 
posterior  surfaces  also  approximate  in 
the  same  way,  so  that  the  bone  is  much 
thicker  at  the  base  than  at  the  apex. 
The  sacrum,  in  the  erect  position  of 
the  body,  is  directed  from  above  downward,  and  from  before  back- 
ward. At  its  upper  edge  it  is  joined,  the  lumbo-sacral  cartilage  inter- 
vening, with  the  fifth  lumbar  vertebra.  The  point  of  junction,  called 
the  promontory  of  the  sacrum,  is  of  great  importance,  as  on 'its  undue 
projection  many  deformities  of  the  brim  of  the  pelvis  depend.  The 
anterior  surface  of  the  bone  is  concave,  and  forms  the  curve  of  the 
sacrum ;  more  marked  in  some  cases  than  in  others.  There  is  also 
more  or  less  concavity  from  side  to  side.  On  it  we  observe  four  aper- 
tures on  each  side,  the  intervertebral  foramina,  giving  exit  to  nerves. 
The  posterior  surface  is  convex,  rough,  and  irregular,  for  the  attach- 
ment of  ligaments  and  muscles,  and  showing  a  ridge  of  vertical  promi- 
nences corresponding  to  the  spinous  processes  of  the  vertebra?. 

The  sacrum  is  generally  described  as  forming  a  keystone  to  the  arch 
constituted  by  the  pelvic  bones,  and  transmitting  the  weight  of  the 
body,  in  consequence  of  its  wedge-like  shape,  in  a  direction  which 
tends  to  thrust  it  downward  and  backward,  as  if  separating  the  ossa 
innominata.  Dr.  Duncan,1  however,  has  shown,  from  a  careful  con- 
sideration of  its  mechanical  relations,  that  it  should  rather  be  regarded 
as  a  strong  transverse  beam,  curved  on  its  anterior  surface,  the  extremi- 
ties of  which  are  in  contact  with  the  corresponding  articular  surfaces 
of  the  ossa  innominata.  The  weight  of  the  body  is  thus  transmitted 
to  the  innominate  bones,  and  through  them  to  the  acetabula  and  the 


Sacrum  and  coccyx. 


Researches  in  Obstetrics,  p.  67. 


36  ORGANS    CONCERNED    IN    PARTURITION. 

femora  (Fig.  3).  There  counter-pressure  is  applied,  and  the  result  is, 
as  we  shall  subsequently  see,  an  important  modifying  influence  on  the 
development  and  shape  of  the  pelvis. 

The  coccyx  (Fig.  2)  is  composed  of  four  small  separate  bones, 
which  eventually  unite  into  one,  but  not  until  late  in  life.  The  upper- 
most of  these  articulates  with  the  apex  of  the  sacrum.  On  its  posterior 
surface  are  two  small  cornua,  which  unite  with  corresponding  points  at 
the  tip  of  the  sacrum.  The  bones  of  the  coccyx  taper  to  a  point.  To 
it  are  attached  various  muscles  which  have  the  effect  of  imparting  con- 
siderable mobility.  During  labor,  also,  it  yields  to  the  mechanical 
pressure  of  the  presenting  part,  so  as  to  increase  the  antero-posterior 
diameter  of  the  pelvic  outlet  to  the  extent  of  an  inch  or  more. 

If,  through  disease  or  accident,  as  sometimes  happens,  the  articular 
cartilages  of  the  coccyx  become  prematurely  ossified,  the  enlargement 
of  the  pelvic  outlet  during  labor  may  be  prevented,  and  considerable 
difficulty  may  thus  arise.  This  is  most  apt  to  happen  in  aged  prirn- 
iparse,  or  in  women  who  have  followed  sedentary  occupations ;  and 
not  infrequently,  under  such  circumstances,  the  bone  fractures  under 
the  pressure  to  which  it  is  subjected  by  the  presenting  part. 

Pelvic  Articulations. — The  pelvic  bones  are  firmly  joined  together 
by  various  articulations  and  ligaments.  The  latter  are  arranged  so  as 
to  complete  the  canal  through  which  the  foetus  has  to  pass,  and  which 
is  in  great  part  formed  by  the  bones.  On  its  internal  surface,  where 
the  absence  of  obstruction  is  of  importance,  they  are  everywhere 
smooth ;  while  externally,  where  strength  is  the  desideratum,  they 
are  arranged  in  larger  masses,  so  as  to  unite  the  bones  firmly  together. 
The  pelvic  articulations  have  been  generally  described  as  symphyses 
or  amphiarthrodia,  a  term  which  is  properly  applied  to  two  articulating 
surfaces,  united  by  fibrous  tissue  in  such  a  way  as  to  prevent  any 
sliding  motion.  It  is  certain,  however,  that  this  is  not  the  case  with 
the  joints  of  the  female  pelvis  during  pregnancy  and  parturition. 
Lenoir  found  that  in  22  females,  between  the  ages  of  eighteen  and 
thirty-five,  there  was  a  distinct  sliding  motion.  Therefore,  the  pelvic 
articulations  are,  strictly  speaking,  to  be  considered  examples  of  the 
class  of  joints  termed  arthrodia. 

Lumbo-sacral  Joint. — The  last  lumbar  vertebra  is  united  to  the 
sacrum  by  ligamentous  union  similar  to  that  which  joins  the  vertebrae 
to  each  other.  The  intervening  fibro-cartilage  forms  a  disk,  which  is 
thicker  in  front  than  behind,  and  this,  in  connection  with  a  similar 
peculiarity  of  the  fifth  lumbar  vertebra,  tends  to  increase  the  sloped 
position  of  the  sacrum,  and  the  angle  which  it  forms  with  the  vertebral 
column.  It  constitutes  the  most  prominent  portion  of  the  promontory 
of  the  sacrum,  and  is  the  part  on  which  the  finger  generally  impinges 
in  vaginal  examinations.  The  anterior  common  vertebral  ligament 
passes  over  the  surface  of  the  joints,  and  we  also  find  the  ligamenta 
subflava  and  the  inter-spinous  ligaments,  as  in  the  other  vertebra. 
The  articular  processes  are  joined  together  by  a  fibrous  capsule,  and 
there  is  also  a  peculiar  ligament,  the  lumbo-sacral,  extending  from  the 
transverse  process  of  the  vertebra  on  each  side,  and  attaching  itself  to 
the  sides  of  the  sacrum  and  the  sacro-iliac  synchondrosis. 


ANATOMY    OF    THE    PELVIS.  37 

Ligaments  of  Coccyx. — The  sacrum  is  joined  to  the  coccyx,  and, 
in  some  cases  at  least,  the  separate  bones  of  the  coccyx  to  each  other, 
by  small  cartilaginous  disks  like  that  connecting  the  sacrum  with  the 
last  lumbar  vertebra.  They  are  further  united  by  anterior  and  pos- 
terior common  ligaments,  the  latter  being  much  the  thicker  and  more 
marked.  In  the  adult  female  a  synovial  membrane  is  found  between 
the  sacrum  and  coccyx,  and  it  is  supposed  that  this  is  formed  under 
the  influence  of  the  movements  of  the  bones  on  each  other. 

Sacro-iliac  Synchondrosis. — The  opposing  articular  surfaces  of 
the  sacrum  and  ilium  are  each  covered  by  cartilages,  that  of  the  sacrum 
being  the  thicker.  These  are  firmly  united,  but,  in  the  female,  accord- 
ing to  Mr.  AVood,1  they  are  always  more  or  less  separated  by  an  inter- 
vening synovial  membrane.  Posterior  to  these  cartilaginous  convex 
surfaces  there  are  strong  interosseous  ligaments,  passing  directly  from 
bone  to  bone,  filling  up  the  interspace  between  them,  and  uniting  them 
firmly.  There  are  also  accessory  ligaments,  such  as  the  superior  and 
anterior  sacro-iliac,  which  are  of  secondary  consequence.  The  pos- 
terior sacro-iliac  ligaments,  however,  are  of  great  obstetric  importance. 
They  are  the  very  strong  attachments  which  unite  the  rough  surfaces 
on  the  posterior  iliac  tuberosities  to  the  posterior  and  lateral  surfaces 
of  the  sacrum.  They  pass  obliquely  downward  from  the  former 
points,  and  suspend,  as  it  were,  the  sacrum  from  them.  According  to 
Duncan,  the  sacrum  has  nothing  to  prevent  its  being  depressed  by 
the  weight  of  the  body  but  these  ligaments,  and  it  is  mainly  through 
them  that  the  weight  of  the  body  is  transmitted  to  the  sacro-cotyloid 
beams  and  the  heads  of  the  femora. 

The  sacro-sciatic  ligaments  are  instrumental  in  completing  the 
canal  of  the  pelvis.  The  greater  sacro-sciatic  ligament  is  attached  by 
a  broad  base  to  the  posterior  inferior  spine  of  the  ilium,  and  to  the 
posterior  surfaces  of  the  sacrum  and  coccyx.  Its  fibres  unite  into  a 
thick  cord,  cross  each  other  in  an  X-like  manner,  and  again  expand 
at  their  insertion  into  the  tuberosity  of  the  ischium.  The  lesser  sacro- 
sciatic  ligament  is  also  attached  with  the  former  to  the  back  parts  of  the 
sacrum  and  coccyx,  its  fibres  passing  to  their  much  narrower  insertion 
at  the  spine  of  the  ischium,  and  converting  the  sacro-sciatic  notch  into 
a  complete  foramen. 

The  obturator  membrane  is  the  fibrous  aponeurosis  that  closes  the 
large  obturator  foramen.  Jouliu 2  supposes  that  along  with  the  sacro- 
sciatic  ligaments,  it  may,  by  yielding  somewhat  to  the  pressure  of  the 
fretal  head,  tend  to  prevent  the  contusion  to  which  the  soft  parts  would 
be  subjected  if  they  were  compressed  between  two  entirelv  osseous 
surfaces. 

Symphysis  Pubis. — The  junction  of  the  pubic  bones  in  front  is 
effected  by  means  of  two  oval  plates  of  fibro-cartilage,  attached  to 
each  articular  surface  by  nipple-shaped  projections,  which  fit  into  cor- 
responding depressions  in  the  bones.  There  is  a  greater  separation 
between  the  bones  in  front  than  behind,  where  the  numerous  fibres  of 
the  cartilaginous  plates  intersect,  and  unite  the  bones  firmly  together. 

i  Todd's  Cyclopedia  ot  Anatomy  and  Physiology,  article  "  Pelvis,"  p.  123. 
8  Traito  d'Accouchements,  p.  11. 


38 


ORGANS    CONCERNED    IN    PARTURITION. 


At  the  upper  and  back  part  of  the  articulation  there  is  an  interspace 
between  the  cartilages,  which  is  lined  by  a  delicate  membrane.  In 

•  i  i 

pregnancy  this  space  often  increases  in  size,  so  as  to  extend  even  to  the 
front  of  the  joint.  The  juncture  is  further  strengthened  by  four  liga- 
ments, the  anterior,  the  posterior,  the  superior,  and  the. sub-pubic.  Of 
these,  the  last  is  the  largest,  connecting  together  the  pubic  bones  and 
forming  the  upper  boundary  of  the  pubic  arch. 


FIG.  3. 


Section  of  pelvis  arid  heads  of  thigh-bones,  showing  the  suspensory  action  of  the  sacro-iliac 
ligaments.    (After  WOOD.) 

Movements  of  Pelvic  Joints. — The  close  apposition  of  the  bones 
of  the  pelvis  might  not  unreasonably  lead  to  the  supposition  that  no 
movement  took  place  between  its  component  parts ;  and  this  is  the 
opinion  which  is  even  yet  held  by  many  anatomists.  It  is  tolerably 
certain,  however,  that  even  in  the  unimpregnated  condition  there  is  a 
certain  amount  of  mobility.  Thus  Zaglas  has  pointed  out 1  that  in  man 
there  is  a  movement  in  an  antero-posterior  direction  of  the  sacro-iliac 
joints  which  has  the  eifect,  in  certain  positions  of  the  body,  of  causing 
the  sacrum  to  project  downward  to  the  extent  of  about  a  line,  thus  nar- 
rowing the  pelvic  brim,  tilting  up  the  point  of  the  bone,  and  thereby 
enlarging  the  outlet  of  the  pelvis.  This  movement  seems  habitually 
brought  into  play  in  the  act  of  straining  during  defecation. 

During  pregnancy  in  some  of  the  lower  animals  there  is  a  very 
marked  movement  of  the  pelvic  articulations,  which  materially  facili- 
tates the  process  of  parturition.  This,  in  the  case  of  the  guinea-pig 
and  cow,  has  been  especially  pointed  out  by  Dr.  Matthews  Duncan.* 
In  the  former  during  labor  the  pelvic  bones  separate  from  each  other 

1  Monthly  Journal  of  Medical  Science,  Sept.  1851. 

2  Researches  in  Obstetrics,  p.  19. 


ANATOMY    OF    THE    PELVIS.  39 

to  the  extent  of  an  inch  or  more.  In  the  latter  the  movements  are 
different,  for  the  symphysis  pubis  is  fixed  by  bony  aukylosis,  and  is 
immovable ;  but  the  sacro-iliac  joints  become  swollen  during  pregnancy, 
and  extensive  movements  in  an  antero-posterior  direction  take  place 
in  them,  which  materially  enlarge  the  pelvic  canal  during  labor. 

It  is  extremely  probable  that  similar  movements  take  place  in 
women,  both  in  the  symphysis  pubis  and  in  the  sacro-iliac  joints, 
although  to  a  less  marked  extent.  These  are  particularly  well  described 
by  Dr.  Duncan.  They  seem  to  consist  chiefly  in  an  elevation  and 
depression  of  the  symphysis  pubis,  either  by  the  ilia  moving  on  the 
sacrum,  or  by  the  sacrum  itself  undergoing  a  forward  movement  on 
an  imaginary  transverse  axis  passing  through  it,  thus  lessening  the 
pelvic  brim  to  the  extent  of  one  or  even  two  lines,  and  increasing,  at 
the  same  time,  the  diameter  of  the  outlet,  by  tilting  up  the  apex  of 
the  sacrum.  These  movements  are  only  an  exaggeration  of  those 
\vhicji  Zaglas  describes  as  occurring  normally  during  defecation.  The 
positions  which  the  parturient  woman  instinctively  assumes  find  an 
explanation  in  these  observations.  During  the  first  stage  of  labor,  when 
the  head  is  passing  through  the  brim,  she  sits,  or  stands,  or  walks  about, 
and  in  these  erect  positions  the  symphysis  pubis  is  depressed,  and  the 
brim  of  the  pelvis  enlarged  to  its  utmost.  As  the  head  advances 
through  the  cavity  of  the  pelvis,  she  can  no  longer  maintain  her  erect 
position,  and  she  lies  down  and  bends  her  body  forward,  which  has 
the  effect  of  causing  a  natatory  motion  of  the  sacrum,  with  correspond- 
ing tilting  up  of  its  apex,  and  an  enlargement  of  the  outlet. 

These  movements  during  parturition  are  facilitated  by  the  changes 
which  are  known  to  take  place  in  the  pelvic  articulations  during  preg- 
nancy. The  ligaments  and  cartilages  become  swollen  and  softened, 
and  the  synovial  membranes  existing  between  the  articulating  surfaces 
become  greatly  augmented  in  size  and  distended  with  fluid.  These 
changes  act  by  forcing  the  bones  apart,  as  the  swelling  of  a  sponge 
placed  between  them  might  do  after  it  had  imbibed  moisture.  The 
reality  of  these  alterations  receives  a  clinical  illustration  from  those 
cases,  which  are  far  from  uncommon,  in  which  these  changes  are 
carried  to  so  extreme  an  extent  that  the  power  of  progression  is 
materially  interfered  with  for  a  considerable  time  after  delivery. 

On  looking  at  the  pelvis  as  a  whole,  we  are  at  once  struck  with  its 
division  into  the  true  and  false  pelvis.  The  latter  portion  (all  that  is 
above  the  brim  of  the  pelvis)  is  of  comparatively  little  obstetric  impor- 
tance, except  in  giving  attachments  to  the  accessory  muscles  of  parturi- 
tion, and  need  not  be  further  considered.  The  brim  of  the  pelvis  is  a 
heart-shaped  opening,  bounded  by  the  sacrum  behind,  the  linea  ilio- 
pectinea  on  either  side,  and  the  symphysis  of  the  pubes  in  front.  All 
below  it  forms  the  cavity,  which  is  bounded  by  the  hollow  of  the 
sacrum  behind,  by  the  inner  surfaces  of  the  innominate  bones  at  the 
sides  and  in  front,  and  by  the  posterior  surface  of  the  symphysis 
pubis.  It  is  in  this  part  of  the  pelvis  that  the  changes  in  direction 
which  the  foetal  head  undergoes  in  labor  are  imparted  to  it.  The  lower 
border  of  this  canal,  or  pelvic  outlet  (Fig.  4),  is  lozenge-shaped,  is 
bounded  by  the  ischiatic  tuberositics  on  either  side,  the  tip  of  the 


ORGANS    COXCERXED    IX    P JLRTURITIOX. 


coccyx  behind,  and  the  under  surface  of  the  pubic  syniphysis  in  front. 
Posteriorly  to  the  tuberosities  of  the  ischia  the  boundaries  of  the  outlet 
are  completed  by  the  sacro-sciatic  ligaments. 


7:      -. 


Outlet  of  petro. 

There  is  a  very  marked  difference  between  the  pelvis  in  the  male 
and  the  female,  and  the  peculiarities  of  the  latter  all  tend  to  facilitate 
the  process  of  parturition.  In  the  female  pelvis  (Fig.  5)  all  the  bones 
are  lighter  in  structure,  and  have  the  points  far  muscular  attachments 
much  less  developed.  The  iliac  bones  are  more  spread  out,  hence  the 
greater  breadth  which  is  observed  in  the  female  figure,  and  the  pecu- 
liar side-to-side  movement  which  all  females  have  in  walking.  The 
tuberosities  of  the  ischia  are  lighter  in  structure  and  farther  apart,  and 
the  ranii  of  the  pubes  also  converge  at  a  much  less  acute  angle.  This 
greater  breadth  of  the  pubic  arch  gives  one  of  the  most  easily  appreci- 
able points  of  contrast  between  die  male  and  the  female  pelvis ;  the 

FK  i. 


pubic  arch  in  the  female  forms  an  angle  of  from  90°  to  100°,  while 
in  the  male  (Fig.  6)  it  averages  from  70°  to  75°.  The  obturator 
foramina  are  more  triangular  in  shape. 


ANATOMY    OF    THE    PELVIS. 


41 


The  whole  cavity  of  the  female  pelvis  is  wider  and  less  funnel- 
shaped  than  in  the  male,  the  symphysis  pubis  is  not  so  deep,  and,  as 
the  promontory  of  the  sacrum  does  not  project  so  much,  the  shape  of 
the  pelvic  brim  is  more  oval  than  in  the  male.  These  differences 
1» 'tween  the  male  and  female  pelvis  are  probably  due  to  the  presence 


FIG.  6. 


The  male  pelvis. 


of  the  female  genital  organs  in  the  true  pelvis,  the  growth  of  which 
increases  its  development  in  width.  In  proof  of  this,  Schroeder  states 
that  in  women  with  congenitally  defective  internal  organs,  and  in 
women  who  have  had  both  ovaries  removed  early  in  life,  tho  pelvis 
has  always  more  or  less  of  the  masculine  type. 


FIG.  7. 


Brim  of  pelvis,  showing  antero-posterior,  c.  v,  oblique,  D,  and  transverse,  T,  diameters. 


Measurements  of  the  Pelvis. — The  measurements  of  the  pelvis 
that  arc  of  most  importance  from  an  obstetric  point  of  view  are  taken 
between  various  points  directly  opposite  to  each  other,  and  are  known 
as  the  diameters  of  the  pelvis. '  Those  of  the  true  pelvis  are  the  diam- 
eters which  it  is  especially  important  to  fix  in  our  memories,  and  it  is 
customary  to  describe  three  in  works  on  obstetrics— the  antero-posterior 


42  ORGANS    CONCERNED    IN    PARTURITION. 

or  conjugate,  the  oblique,  and  the  transverse — although,  of  course,  the 
measurements  may  be  taken  at  any  opposing  points  in  the  circumfer- 
ence of  the  bones.  The  antero-posterior  (diameter  Conjugata  vera, 
c.  v,  sacro-pubic\  at  the  brim  (Fig.  7),  is  taken  from  the  upper  part  of 
the  posterior  surface  of  the  symphysis  pubis  to  the  centre  of  the  promon- 
tory of  the  sacrum ;  in  the  cavity,  from  the  centre  of  the  symphysis 
pubis  to  a  corresponding  point  in  the  body  of  the  third  piece  of  the 
sacrum  ;  and  at  the  outlet  (coccv-pubic),  from  the  lower  border  of  the 
symphysis  pubis  to  the  tip  of  the  coccyx.  The  oblique  (diameter 
Diagonalis,  D),  at  the  brim,  is  taken  from  the  sacro-iliac  joint  on  either 
side  to  a  point  of  the  brim  corresponding  with  the  ilio-pectiueal  emi- 
nence— that  starting  from  the  right  sacro-iliac  joint  being  called  the 
right  oblique  (diameter  Diagonalis  dextra,  D.  D),  that  from  the  left  the 
left  oblique  (diameter  Diagonalis  sinistra,  D.  s) ;  in  the  cavity  a  similar 
measurement  is  made  at  the  same  level  as  the  conjugate  ;  while  at  the 
outlet  an  oblique  diameter  is  not  usually  measured.  The  transverse 
(diameter  Tmnsversa,  T)  is  taken,  at  the  brim,  from  a  point  midway 
between  the  sacro-iliac  joint  and  the  ilio-pectiueal  eminence  to  a  cor- 
responding point  at  the  opposite  side  of  the  brim  ;  in  the  cavity,  from 
points  in  the  same  plane  as  the  conjugate  and  oblique  diameters ;  and 
at  the  outlet,  from  the  centre  of  the  inner  border  of  one  ischial  tuber- 
osity  to  that  of  the  other.  The  measurements  given  by  various  writers 
diifer  considerably  and  vary  somewhat  in  different  pelves.  Taking  the 
average  of  a  large  number,  the  following  may  be  given  as  the  standard 
measurements  of  the  female  pelvis : 

Antero-posterior,  Oblique,  Transverse, 

c.  v.  D.  T. 

Inches.  Inches.  Inches. 

Brim 4.25  4.8  5.2 

Cavity 4.7  5.2  4.75 

Outlet 5.0  4.2 

It  will  be  observed  that  the  lengths  of  the  corresponding  diameters 
at  different  places  vary  greatly ;  thus,  while  the  transverse  (T)  is  longest 
at  the  brim,  the  oblique  (D)  is  longest  in  the  cavity,  and  the  antero- 
posterior  (c.  v)  at  the  outlet.  It  will  be  subsequently  seen  that  this 
fact  is  of  great  practical  importance  in  studying  the  mechanism  of 
delivery,  for  the  head  in  its  descent  through  the  pelvis  alters  its  posi- 
tion in  such  a  way  as  to  adapt  itself  to  the  longest  diameter  of  the 
pelvis ;  thus,  as  it  passes  through  the  cavity  it  lies  in  the  oblique  (D) 
diameter,  and  then  rotates  so  as  to  be  expelled  in  the  antero-pos- 
terior (c.  v)  diameter  of  the  outlet. 

In  thinking  of  these  measurements  of  the  pelvis,  it  must  not  be 
forgotten  that  they  are  taken  in  the  dried  bones,  and  that  they  are 
considerably  modified  during  life  by  the  soft  parts.  This  is  especially 
the  case  at  the  brim,  where  the  projection  of  the  psoas  and  iliacns 
muscles  lessens  the  transverse  (T)  diameter  about  half  an  inch,  while 
the  antero-posterior  (c.  v)  diameter  of  the  brim,  and  all  the  diameters 
of  the  cavity,  are  lessened  by  a  quarter  of  an  inch.  The  right  oblique 
diameter  (D.  D)  of  the  brim  is,  even  in  the  dried  pelvis,  found  to  be  on 
an  average  slightly  longer  than  the  left  (D.  s),  probably  on  account  of 
the  increased  development  of  the  right  side  of  the  pelvis  from  the  greater 


ANATOMY    OF    THE    PELVIS. 


43 


FIG.  8. 


use  made  of  the  right  leg ;  but,  in  addition  to  this,  the  left  oblique 
diameter  (D.  s)  is  somewhat  lessened  during  life  by  the  presence  of 
the  rectum  on  the  left  side.     The 
advantage    gained    by    the    com- 
paratively frequent  passage  of  the 
head    through    the   pelvis  in   the 
right  oblique   diameter   (D.  D)   is 
thus  explained. 

There  are  one  or  two  other 
measurements  of  the  true  pelvis 
which  are  sometimes  given,  but 
which  are  of  secondary  impor- 
tance. One  of  these,  the  sacro- 
cotyloid  diameter,  is  that  between 
the  promontory  of  the  sacrum  and 
a  point  immediately  above  the 
cotyloid  cavity,  and  averages  from 
3.4  to  3.5  inches.  Another,  called 
by  Wood  the  lower  or  inclined 
conjugate  diameter  (diameter  Con- 
jugata  diagonalis,  c.  D),  is  that  be- 
tween the  centre  of  the  lower  mar- 
gin of  the  symphysis  pubis  and 
the  promontory  of  the  sacrum,  and 
averages  half  an  inch  more  than 
the  antero-posterior  diameter  of 
the  brim  [*].  These  measurements 
are  chiefly  of  importance  in  rela- 
tion to  certain  pelvic  deformities. 

The  external  measurements  of 
the  pelvis  are  of  no  real  conse- 
quence in  normal  parturition,  but 
they  may  help  us,  in  certain  cases, 
to  estimate  the  existence  and 
amount  of  deformities.  Those 
which  are  generally  given  are:  Be- 
tween the  anterior  superior  iliac 

spines,  10  inches;  between  the  central  points  of  the  crests  of  the  iliar 
10|  inches ;  between  the  spiuous  process  of  the  last  lumbar  vertebra  and 
the  upper  part  of  the  symphysis  pubis  (external  conjugate),  7  inches. 

Planes  of  the  Pelvis. — By  the  planes  of  the  pelvis  are  meant  imagi- 
nary levels  at  any  portion  of  its  circumference.  If  we  were  to  cut  out 
a  piece  of  cardboard  so  as  to  fit  the  pelvic  cavity,  and  place  it  either  at 
the  brim  or  elsewhere,  it  would  represent  the  pelvic  plane  at  that  par- 
ticular part,  and  it  is  obvious  that  we  may  conceive  as  many  planes  as 
we  desire.  Observation  of  the  angle  which  the  pelvic  planes  form 
with  the  horizon  shows  the  great  obliquity  at  which  the  pelvis  is  placed 
in  regard  to  the  spinal  column.  Thus  the  angle  A  B  I  (Fig.  9)  repre- 


Section  of  pelvis,  showing  the  diameters. 


The  c.  D  is  frequently  used  in  Continental  reports,  instead  of  the  c.  v.— ED.] 


44 


ORGANS    CONCERNED    IN    PARTURITION. 


sents  the  inclination  to  the  horizon  of  the  plane  of  the  pelvic  brim,  i  B, 
and  is  estimated  to  be  about  60°,  while  the  angle  which  the  same  plane 
forms  with  the  vertebral  column  is  about  150°.  The  plane  of  the  out- 
let forms,  with  the  coccyx  in  its  usual  position,  an  angle  with  the  hori- 
zon of  about  11°,  but  which  varies  greatly  with  the  movements  of  the 
tip  of  the  coccyx,  and  the  degree  to  which  it  is  pushed  back  during 
parturition.  These  figures  must  only  be  taken  as  giving  an  approxi- 
mate idea  of  the  inclination  of  the  pelvis  to  the  spinal  column,  and  it 


Planes  of  the  pelvis  with  horizon.  A  B.  Horizon,  c  D.  Vertical  line.  A  B  i.  Angle  of  inclina- 
nation  of  pelvis  to  horizon,  equal  to  60°.  B  i  c.  Angle  of  inclination  of  pelvis  to  spinal  column, 
equal  to  150°.  c  u.  Angle  of  inclination  of  sacrum  to  spinal  column,  equal  to  130°.  E  F.  Axis  of 
pelvic  inlet.  L  M.  Mid-plane  in  the  middle  line.  N.  Lowest  point  of  mid-plane  of  ischium. 

must  be  remembered  that  the  degree  of  inclination  varies  considerably 
in  the  same  female  at  different  times,  in  accordance  with  the  position 
of  the  body.  During  pregnancy  especially,  the  obliquity  of  the  brim 
is  lessened  by  the  patient  throwing  herself  backward  in  order  to  sup- 
port more  easily  the  weight  of  the  gravid  uterus.  The  height  of  the 
promontory  of  the  sacrum  above  the  upper  margin  of  the  syrnphysis 
pubis  is,  on  an  average,  about  three  and  three-quarters  inches,  and  a 
line  passing  horizontally  backward  from  the  latter  point  would  im- 
pinge on  the  junction  of  the  second  and  third  coccygeal  bones. 

Axes  of  the  Parturient  Canal. — By  the  axis  of  the  pelvis  is  meant 
an  imaginary  line  which  indicates  the  direction  which  the  foetus  takes 
during  its  expulsion.  The  axis  of  the  brim  (Fig.  10)  is  a  line  drawn 
perpendicular  to  its  plane,  which  would  extend  from  the  umbilicus  to 
about  the  apex  of  the  coccyx  ;  the  axis  of  the  outlet  of  the  bony  pelvis 
intersects  this,  and  extends  from  the  centre  of  the  promontory  of  the 
sacrum  to  midway  between  the  tuberosities  cf  the  ischia.  The  axis  of 


ANATOMY    OF    THE    PELYIS. 
FIG.  10. 


45 


\D 


Axes  of  the  pelvis.    A,  Axis  of  superior  plane.  B.  Axis  of  mid-plane,    c.  Axis  of  inferior  plane. 
D.  Axis  of  canal.    E.  Horizon. 

the  entire  pelvic  canal  is  represented  by  the  sum  of  the  axes  of  an 
indefinite  number  of  planes  at  different  levels  of  the  pelvic  cavity, 
which  forms  an  irregular  parabolic  line,  as  represented  in  the  accom- 
panying diagram  (Fig.  10,  A  D). 

FlQ.  11. 


Representing  general  axis  of  parturient  canal,  including  the  uterine  cavity  and  soft  parts. 


46 


ORGANS    CONCERNED    IN    PARTURITION. 


It  must  be  borne  in  mind,  however,  that  it  is  not  the  axis  of  the 
bony  pelvis  alone  that  is  of  importance  in  obstetrics.  We  must  always 
remember,  in  considering  this  subject,  that  the  general  axis  of  the  par- 
turient canal  (Fig.  11)  also  includes  that  of  the  uterine  cavity  above, 
and  of  the  soft  parts  below.  These  are  variable  in  direction  according 
to  circumstances ;  and  it  is  only  the  axis  of  that  portion  of  the  partu- 
rient canal  extending  between  the  plane  of  the  pelvic  brim  and  a  plane 
between  the  lower  edge  of  the  pubic  symphysis  and  the  base  of  the 
coccyx  that  is  fixed.  The  axis  of  the  lower  part  of  the  canal  will  vary 
according  to  the  amount  of  distention  of  the  perineum  during  labor ; 
but  when  this  is  stretched  to  its  utmost,  just  before  the  expulsion  of 
the  head,  the  axis  of  the  plane  between  the  edge,  of  the  distended  peri- 
neum and  the  lower  border  of  the  symphysis  looks  nearly  directly  for- 
Avard.  The  axis  of  the  uterine  cavity  generally  corresponds  with  that 
of  the  pelvic  brim,  but  it  may  be  much  altered  by  abnormal  positions 
of  the  uterus,  such  as  anteversion  from  laxity  of  the  abdominal  walls. 
The  foetus,  under  such  circumstances,  will  not  enter  the  brim  in  its 
proper  axis,  and  difficulties  in  labor  arise.  A  knowledge  of  the  gen- 
eral direction  of  the  parturient  canal 
FIG.  12.  is  of  great  importance  in  practical 

midwifery  in  guiding  us  to  the  intro- 
duction of  the  hand  or  instruments  in 
obstetric  operations,  and  in  showing 
us  how  to  obviate  difficulties  arising 
from  such  accidental  deviations  of  the 
uterus  as  have  just  been  alluded  to. 

Cavity  of  the  Pelvis. — The  arrange- 
ments of  the  bones  in  the  interior  of 
the  pelvic  canal  (Fig.  12)  are  impor- 
tant in  relation  to  the  mechanism  of 
delivery.  A  line  passing  between  the 
spine  of  the  ischiurn  and  the  ilio-pec- 
tineal  eminence  divides  the  inner  sur- 
face of  the  ischial  bone  into  two  smooth 
side  view  of  pelvis.  plane  surfaces,  which  have  received 

the  name  of  the  planes  of  the  ischiurn. 

Two  other  planes  are  formed  by  the  inner  surfaces  of  the  pubic  bones 
in  front  and  by  the  upper  portion  of  the  sacrum  behind,  both  having 
a  direction  downward  and  backward.  In  studying  the  mechanism  of 
delivery,  it  will  be  seen  that  many  obstetricians  attribute  to  these 
planes,  in  conjunction  Avith  the  spines  of  the  ischia,  a  very  important 
influence  in  effecting  rotation  of  the  foetal  head  from  the  oblique  to  the 
antero-posterior  diameter  of  the  pehTis. 

Development  of  the  Pelvis. — The  peculiarities  of  the  peh'is  during 
infancy  and  childhood  are  of  interest  as  leading  to  a  knowledge  of  the 
manner  in  AA'hich  the  form  obserATed  during  adult  life  is  impressed  upon 
it.  The  sacrum  in  the  peUTis  of  the  child  (Fig.  13)  is  less  de\Teloped 
transversely,  and  is  much  less  deeply  curved  than  in  the  adult.  The 
pubes  is  also  much  shorter  from  side  to  side,  and  the  pubic  arch  is  an 
acute  angle.  The  result  of  this  narroAvuess  of  both  the  pubes  and 


ANATOMY    OF    THE    PELVIS.  47 

sacrum  is  that  the  transverse  (T)  diameter  of  the  pelvic  brim  is  shorter 
instead  of  longer  than  the  antero-posterior  (c.  v).  The  sides  of  the 
pelvis  have  a  tendency  to  parallelism,  as  well  as  the  antero-posterior 
walls ;  and  this  is  stated  by  Wood  to  be  a  peculiar  characteristic  of  the 
infantile  pelvis.  The  iliac  bones  are  not  spread  out  as  in  adult  life, 
so  that  the  centres  of  the  crests  of  the  ilia  are  not  more  distant  from 
each  other  than  the  anterior  superior  spines.  The  cavity  of  the  true 
pelvis  is  small,  and  the  tuberosities  of  the  ischia  are  proportionately 
nearer  to  each  other  than  they  afterward  become ;  the  pelvic  viscera 
are  consequently  crowrded  up  into  the  abdominal  cavity,  wrhich  is,  for 
this  reason,  much  more  prominent  in  children  than  in  adults.  The 
bones  are  soft  and  semi-cartilaginous  until  after  the  period  of  puberty, 
and  yield  readily  to  the  mechanical  influences  to  which  they  are 
subjected;  and  the  three  divisions  of  the  innominate  bone  remain 
separate  until  about  the  twentieth  year. 

FIG.  13. 


Pelvis  of  a  child. 


As  the  child  grows  older  the  transverse  development  of  the  sacrum 
increases,  and  the  pelvis  begins  to  assume  more  and  more  of  the  adult 
shape.  The  mere  growth  of  the  bones,  however,  is  not  sufficient  to 
account  for  the  change  in  the  shape  of  the  pelvis,  and  it  has  been  well 
shown  by  Duncan  that  this  is  chiefly  produced  by  the  pressure  to  which 
the  bones  are  subjected  during  early  life.  The  iliac  bones  are  acted 
upon  by  two  principal  and  opposing  forces.  One  is  the  weight  of  the 
body  above,-  which  acts  vertically  upon  the  sacral  extremity  of  the 
iliac  beam  through  the  strong  posterior  sacro-iliac  ligaments,  and  tends 
to  throw  the  lower  or  acetabular  ends  of  the  sacro-cotyloid  beams  out- 
ward. This  outward  displacement,  however,  is  resisted,  partly  by  the 
junction  between  the  two  acetabular  ends  at  the  front  of  the  pelvis, 
but  chiefly  by  the  opposing  force,  which  is  the  upward  pressure  of  the 
lower  extremities  through  the  femurs.  The  result  of  these  counteract- 
ing forces  is  that  the  still  soft  bones  bend  near  their  junction  with 
the  sacrum,  and  thus  the  greater  transverse  development  of  the  pelvic 
brim  characteristic  of  adult  life  is  established.  In  treating  of  pelvic 


48  ORGANS    CONCERNED    IN    PARTURITION. 

deformities  it  will  be  seen  that  the  same  forces  applied  to  diseased  and 
softened  bones  explain  the  peculiarities  of  form  that  they  assume. 

Pelvis  in  Different  Races. — The.  researches  that  have  been  made 
on  the  differences  of  the  pelvis  in  different  races  prove  that  these  are 
not  so  great  as  might  have  been  expected.  Joulin  pointed  out  that  in 
all  human  pelves  the  transverse  (T)  diameter  was  larger  than  the 
antero-posterior  (c.  v),  while  the  reverse  was  the  case  in  all  the  lower 
animals,  even  in  the  highest  simise.  This  observation  has  been  more 
recently  confirmed  by  Yon  Franque,1  who  has  made  careful  measure- 
ments of  the  pelvis  in  various  races.  In  the  pelvis  of  the  gorilla  the 
oval  form  of  the  brim,  resulting  from  the  increased  length  of  the 
conjugate  (c.  v)  diameter,  is  very  marked.  In  certain  races  there  is 
so  far  a  tendency  to  animality  of  type  that  the  difference  between  the 
transverse  (T)  and  conjugate  (c.  v)  diameters  is  much  less  than  in 
European  women,  but  it  is  not  sufficiently  marked  to  enable  us  to 
refer  any  given  pelvis  to  a  particular  race.  Von  Franque  makes  the 
general  observation  that  the  size  of  the  pelvis  increases  from  south  to 
north,  but  that  the  conjugate  (c.  v)  diameter  increases  in  proportion  to 
the  transverse  (T)  in  southern  races. 

Soft  Parts  in  Connection  with  Pelvis. — In  closing  the  description 
of  the  pelvis,  the  attention  of  the  student  must  be  directed  to  the 
muscular  and  other  structures  which  cover  it.  It  has  already  been 
pointed  out  that  the  measurements  of  the  pelvic  diameters  are  con- 
siderably lessened  by  the  soft  parts,  which  also  influence  parturition 
in  other  ways.  Thus,  attached  to  the  crests  of  the  ilia  are  strong 
muscles  which  not  only  support  the  enlarged  uterus  during  pregnancy, 
but  are  powerful  accessory  muscles  in  labor :  in  the  pelvic  cavity  are 
the  obturator  and  pyriformis  muscles  lining  it  on  either  side ;  the 
pelvic  cellular  tissue  and  fascia? ;  the  rectum  and  bladder ;  the  vessels 
and  nerves,  pressure  on  which  often  gives  rise  to  cramps  and  pains 
during  pregnancy  and  labor;  while  below,  the  outlet  of  the  pelvis  is 
closed,  and  its  axis  directed  forward  by  the  numerous  muscles  forming 
the  floor  of  the  pelvis  and  perineum.  The  structures  closing  the 
pelvis  have  been  accurately  described  by  Dr.  Berry  Hart,2  who  points 
out  that  they  form  a  complete  diaphragm  stretching  from  the  pubis  to 
the  sacrum,  in  which  are  three  "faults"  or  "  slits"  formed  by  the 
orifices  of  the  urethra,  vagina,  and  rectum.  The  first  of  these  is  a 
mere  capillary  slit,  the  last  is  closed  by  a  strong  muscular  sphincter, 
while  the  vagina,  in  a  healthy  condition,  is  also  a  mere  slit,  with  its 
walls  in  accurate  apposition.  Hence  it  follows  that  none  of  these 
apertures  impairs  the  structural  efficiency  of  the  pelvic  floor,  or  the 
support  it  gives  to  the  structures  above  it. 

Scanzoni's  Beitrage,  1867. 

The  Structural  Anatomy  of  the  Female  Pelvic  Floor. 


THE  FEMALE  GENERATIVE  ORGANS.          49 


CHAPTER  II. 
/ 

THE  FEMALE  GENERATIVE  ORGANS. 

THE  reproductive  organs  in  the  female  are  conveniently  divided, 
according  to  their  function,  into :  1 .  The  external  or  copulative  organs, 
which  are  chiefly  concerned  in  the  act  of  insemination,  and  are  only 
of  secondary  importance  in  parturition  :  they  include  all  the  organs 
situate  externally  which  form  the  vulva ;  and  the  vagina,  which  is 
placed  internally  and  forms  the  canal  of  communication  between  the 
uterus  and  the  vulva.  2.  The  internal  or  formative  organs :  they 
include  the  ovaries,  which  are  the  most  important,  of  all,  as  being 
those  in  which  the  ovule  is .  formed ;  the  Fallopian  tubes,  through 
which  the  ovule  is  carried  to  the  uterus ;  and  the  uterus,  in  which  the 
impregnated  ovule  is  lodged  and  developed. 

1.  The  external  organs  consist  of: 

The  mons  Veneris  (Fig.  14,  F),  a  cushion  of  adipose  and  fibrous 
tissue  which  forms  a  rounded  projection  at  the  upper  part  of  the  vulva. 
It  is  in  relation  above  with  the  lower  part  of  the  hypogastric  region, 
from  which  it  is  often  separated  by  a  furrow,  and  below  it  is  con- 
tinuous with  the  labia  majora  on  either  side.  It  lies  over  the  sym- 
physis  and  horizontal  rami  of  the  pubes.  After  puberty  it  is  covered 
with  hair.  On  its  integument  are  found  the  openings  of  numerous 
sweat  and  sebaceous  glands. 

The  labia  majora  (Fig.  14,  a)  form  two  symmetrical  sides  to  the 
longitudinal  aperture  of  the  vulva.  They  have  two  surfaces,  one 
external,  of  ordinary  integument,  covered  with  hair,  and  another 
internal,  of  smooth  mucous  membrane,  in  apposition  with  the  corre- 
sponding portion  of  the  opposite  labium,  and  separated  from  the 
external  surface  by  a  free  convex  border.  They  are  thicker  in  front, 
where  they  run  into  the  mons  Veneris,  and  thinner  behind,  where  they 
are  united,  in  front  of  the  perineum,  by  a  thin  fold  of  integument 
called  the  fourchette,  which  is  almost  invariably  ruptured  in  the  first 
labor.  In  the  virgin  the  labia  are  closely  in  apposition,  and  conceal 
the  rest  of  the  generative  organs.  After  childbearing  they  become 
more  or  less  separated  from  each  other,  and  in  the  aged  they  waste, 
and  the  internal  nymphse  protrude  through  them.  Both  their  cuta- 
neous and  mucous  surfaces  contain  a  large  number  of  sebaceous  glands, 
opening  either  directly  on  the  surface  or  into  the  hair  follicles.  In 
structure  the  labia  are  composed  of  connective  tissue,  containing  a 
varying  amount  of  fat,  and  parallel  with  their  external  surface  are 
placed  tolerably  close  plexuses  of  elastic  tissue,  interspersed  with 
regularly  arranged  smooth  muscular  fibres.  These  fibres  are  described 
by  Broca  as  forming  a  membranous  sac,  resembling  the  dartos  of  the 
scrotum,  to  which  the  labia  majora  are  analogous.  Toward  its  upper 

4 


50 


ORGANS    CONCERNED    IN    PARTURITION. 


and  narrower  end  this  sac  is  continuous  with  the  external  inguinal 
ring,  and  in  it  terminate  some  of  the  fibres  of  the  round  ligament. 
The  analogy  with  the  scrotum  is  further  borne  out  by  the  occasional 
hernial  protrusion  of  the  ovary  into  the  labium,  corresponding  to  the 
normal  descent  of  the  testis  in  the  male. 


External  genitals  of  virgin  with  diaphragmatic  hymen,  a.  Labium  majus.  b.  Labium  minus. 
c.  Prseputium  clitoridis.  d.  Glaus  clitoridis.  e.  Vestibule  just  above  urethral  orifice.  F.  Mous 
Veneris.  (After  SAPPEY.) 

The  labia  minora,  or  nympliSB  (Fig.  14,  6),  are  two  folds  of 
mucous  membrane,  commencing  below,  on  either  side,  about  the  centre 
of  the  internal  surface  of  the  labium  externum  ;  they  converge  as  they 
proceed  upward,  bifurcating  as  they  approach  each  other.  The  lower 
branch  of  this  bifurcation  is  attached  to  the  clitoris  (Fig.  14,  d\  while 
the  upper  and  larger  unites  with  its  fellow  of  the  opposite  side,  and 
forms  a  fold  round  the  clitoris,  known  as  its  prepuce,  c.  The  nymphse 
are  usually  entirely  concealed  by  the  labia  majora,  but  after  child- 
bearing  and  in  old  age  they  project  somewhat  beyond  them ;  then  they 
lose  their  delicate  pink  color  and  soft  texture,  and  become  brown,  dry, 
and  like  skin  in  appearance.  This  is  especially  the  case  in  some  of 
the  negro  races,  in  whom  they  form  long  projecting  folds  called  the 
apron. 


THE  FEMALE  GENERATIVE  ORGANS.          51 

The  surfaces  of  the  nymphee  are  covered  with  tessellated  epithelium, 
and  over  them  are  distributed  a  large  number  of  vascular  papilla?, 
somewhat  enlarged  at  their  extremities,  and  sebaceous  glands,  which 
are  more  numerous  on  their  internal  surfaces.  The  latter  secrete  an 
odorous,  cheesy  matter,  which  lubricates  the  surface  of  the  vulva,  and 
prevents  its  folds  adhering  to  each  other.  The  nymphse  are  composed 
of  trabeculae  of  connective  tissue,  containing  muscular  fibres. 

The  clitoris  (Fig.  14,  d)  is  a  small  erectile  tubercle  situated  about 
half  an  inch  below  the  anterior  commissure  of  the  labia  majora.  It 
is  the  analogue  of  the  penis  in  the  male,  and  is  similar  to  it  in  struc- 
ture, consisting  of  two  corpora  cavernosa,  separated  from  each  other 
by  a  fibrous  septum.  The  crura  are  covered  by  the  ischio-cavernous 
muscles,  which  serve  the  same  purpose  as  in  the  male.  It  has  also  a 
suspensory  ligament.  The  corpora  cavernosa  are  composed  of  a  vas- 
cular plexus  with  numerous  traversing  muscular  fibres.  The  arteries 
are  derived  from  the  internal  pudic  artery,  which  gives  a  branch,  the 
cavernous,  to  each  half  of  the  organ ;  there  is  also  a  dorsal  artery  dis- 
tributed to  the  prepuce.  According  to  Gussenbauer,  these  cavernous 
arteries  pour  their  blood  directly  into  large  veins,  and  a  finer  venous 
plexus  near  the  surface  receives  arterial  blood  from  small  arterial 
branches.  By  these  arrangements  the  erection  of  the  organ  which 
takes  place  during  sexual  excitement  is  favored.  The  nervous  supply 
of  the  clitoris  is  large,  being  derived  from  the  internal  pudic  nerve, 
which  supplies  branches  to  the  corpora  cavernosa,  and  terminates  in 
the  glans  and  prepuce,  where  Paccinian  corpuscles  and  terminal  bulbs 
are  to  be  found.  On  this  account  the  clitoris  has  been  supposed  by 
some  to  be  the  chief  seat  of  voluptuous  sensation  in  the  female. 

The  vestibule  (Fig.  14,  e)  is  a  triangular  space,  bounded  at  its  apex 
by  the  clitoris,  and  on  either  side  by  the  folds  of  the  nymphse.  It  is 
smooth,  and,  unlike  the  rest  of  the  vulva,  is  destitute  of  sebaceous 
glands,  although  there  are  several  groups  of  muciparous  glands  open- 
ing on  its  surface.  At  the  centre  of  the  base  of  the  triangle,  which  is 
formed  by  the  upper  edge  of  the  opening  of  the  vagina,  is  a  promi- 
nence, distant  about  an  inch  from  the  clitoris,  on  which  is  the  orifice 
of  the  urethra.  This  prominence  can  be  readily  made  out  by  the 
finger,  and  the  depression  upon  it — leading  to  the  urethra — is  of  im- 
portance as  our  guide  in  passing  the  female  catheter.  This  little 
operation  ought  to  be  performed  without  exposing  the  patient,  and 
it  is  done  in  several  ways.  The  easiest  is  to  place  the  tip  of  the  index 
finger  of  the  left  hand  (the  patient  lying  on  her  back)  on  the  apex  of 
the  vestibule,  and  slip  it  gently  down  until  we  feel  the  bulb  of  the 
urethra,  and  the  dimple  of  its  orifice,  which  is  generally  readily  found. 
If  there  is  any  difficulty  in  finding  the  orifice,  it  is  well  to  remember 
that  it  is  placed  immediately  below  the  sharp  edge  of  the  lower  border 
of  the  symphysis  pubis,  which  will  guide  us  to  it.  The  catheter  (and 
a  male  elastic  catheter  is  always  the  best,  especially  during  labor,  when 
the  urethra  is  apt  to  be  stretched)  is  then  passed  under  the  thigh  of  the 
patient,  and  directed"  to  the  orifice  of  the  urethra  by  the  finger  of  the 
left  hand,  which  is  placed  upon  it.  We  must  be  careful  that  the 
instrument  is  really  passed  into  the  urethra,  and  not  into  the  vagina. 


52  ORGANS    CONCERNED    IN    PARTURITION. 

It  is  advisable  to  have  a -few  feet  of  elastic  tubing  attached  to  the  end 
of  the  catheter,  so  that  the  urine  can  be  passed  into  a  vessel  under  the 
bed  without  uncovering  the  patient.  If  the  patient  be  on  her  side,  in 
the  usual  obstetric  position,  the  operation  can  be  more  readily  per- 
formed by  placing  the  tip  of  the  finger  in  the  vagina,  and  feeling  its 
upper  edge.  The  orifice  of  the  urethra  lies  immediately  above  this, 
and  if  the  catheter  be  slipped  along  the  palmar  surface  of  the  finger,  it 
can  generally  be  inserted  without  much  trouble.  If,  however,  as  is 
often  the  case  during  labor,  the  parts  are  much  swollen,  it  may  be  diffi- 
cult to  find  the  aperture,  and  it  is  then  always  better  to  look  for  the 
opening  than  to  hurt  the  patient  by  long-continued  efforts  to  feel  it. 

The  urethra  is  a  canal  one  and  a  half  inches  in  length,  and  it  is 
intimately  connected  with  the  anterior  wall  of  the  vagina,  through 
which  it  may  be  felt.  It  is  composed  of  muscular  and  erectile  tissue, 
and  is  remarkable  for  its  extreme  dilatability,  a  property  which  is 
turned  to  practical  account  in  some  of  the  operations  for  stone  in  the 
female  bladder. 

About  an  eighth  of  an  inch  above  its  orifice  are  the  openings  of  two 
glandular  structures  situated  in  its  muscular  walls.  They  are  about 
three-quarters  of  an  inch  in  length,  and  were  first  described  by  Pro- 
fessor Skene,  of  Brooklyn.1 

The  orifice  of  the  vagina  is  situated  immediately  below  the  bulb 
of  the  urethra.  In  virgins  it  is  a  circular  opening,  but  in  women  who 
have  borne  children  or  practised  sexual  intercourse  it  is,  in  the  undis- 
tended  state,  a  fissure,  running  transversely,  and  at  right  angles  to  that 
between  the  labia.2  In  virgins  it  is  generally  more  or  less  blocked  up 
by  a  fold  of  mucous  membrane,  containing  some  cellular  tissue  and 
muscular  fibres,  with  vessels  and  nerves,  which  is  known  as  the  hymen. 
This  is  continuous  with  the  anterior  extremity  of  the  vagina,  the 
mucous  membrane  of  which  lines  its  internal  surface ;  that  covering 
its  external  surface  being  derived  from  the  mucous  membrane  of  the 
vulva.3  The  hymen  is  developed  late  in  the  female  embryo,  and  at 
first  is  seen  in  the  form  of  two  projections  on  either  side  of  the  uro- 
genital  fissure,  which  ultimately  unite  in  the  central  line.  At  birth  it 
is  very  prominent,  and  has  occasionally  been  taken  for  the  internal 
labia.*  It  is  most  often  crescentic  in  shape,  with  the  concavity  of  the 
crescent  looking  upward  ;  sometimes,  however,  it  is  circular  with  a 
central  opening,  or  cribriform  ;  or  it  may  even  be  entirely  imperforate, 
and  this  gives  rise  to  the  retention  of  the  menstrual  secretion.  These 
varieties  of  form  depend  on  the  peculiar  mode  of  development  of  the 
fold  of  vaginal  mucous  membrane  which  blocks  up  the  orifice  of  the 
vagina  in  the  foetus,  and  from  which  the  hymen  is  formed.  The  density 
of  the  membrane  also  varies  in  different  individuals.  Most  usually 
it  is  very  slight,  so  as  to  be  ruptured  in  the  first  sexual  approaches, 
or  even  by  some  accidental  circumstance,  such  as  stretching  the  limbs, 
so  that  its  absence  cannot  be  taken  as  evidence  of  want  of  chastity. 
A  knowledge  of  this  fact  is  of  considerable  importance  from  a  medico- 

1  Amer.  Journ.  of  Obstetrics,  1880,  vol.  xiii.  p.  265.  -  Hart  :  op.  cit. 

s  Budin :  Reeherches  sur  1'Hymen  et  1'Orifice  vaginal,  1879. 
*  Doran :  Gynecological  Operations,  p.  7. 


THE  FEMALE  GENERATIVE  ORGANS.          53 

legal  point  of  view.  Sometimes  it  is  so  tough  as  to  prevent  inter- 
course altogether,  and  may  require  division  by  the  knife  or  scissors 
before  this  can  be  effected ;  and  at  others  it  rather  unfolds  than  rup- 
tures, so  that  it  may  exist  even  after  impregnation  has  been  effected, 
and  it  has  been  met  with  intact  in  women  who  have  habitually  led 
unchaste  lives.  In  a  few  rare  cases  it  has  even  formed  an  obstacle  to 
delivery,  and  has  required  incision  during  labor. 

The  carunculae  xnyrtiformes  are  small  fleshy  tubercles  varying 
from  two  to  five  in  number,  situated  round  the  orifice  of  the  vagina, 
and  which  are  generally  supposed  to  be  the  remains  of  the  ruptured 
hymen.  Schroeder,  however,  maintains  that  they  are  only  formed 
after  childbearing,  in  consequence  of  parts  of  the  hymen  having  been 
destroyed  by  the  injuries  received  during  the  passage  of  the  child. 

Vulvo- vaginal  Glands. — Near  the  posterior  part  of  the  vaginal 
orifice,  and  below  the  superficial  perineal  fascia,  are  situated  two  con- 
glomerate glands  which  are  the  analogues  of  Cowper's  glands  in  the  male. 
Each  of  these  is  about  the  size  and  shape  of  an  almond,  and  is  contained 
in  a  cellular  fibrous  envelope.  Internally  they  are  of  a  yellowish- 
white  color,  and  are  composed  of  a  number  of  lobules  separated  from 
each  other  by  prolongations  of  the  external  envelope.  These  give  origin 
to  separate  ducts  which  unite  into  a  common  canal,  about  half  an  inch 
in  length,  which  opens  in  front  of  the  attached  edge  of  the  hymen  in 
virgins,  and  in  married  women  at  the  base  of  one  of  the  carunculae 
myrtiformes.  According  to  Huguier,  the  size  of  the  glands  varies 
much  in  different  women,  and  they  appear  to  have  some  connection 
with  the  ovary,  as  he  has  always  found  the  largest  gland  to  be  on  the 
same  side  as  the  largest  ovary.  They  secrete  a  glairy,  tenacious  fluid, 
which  is  ejected  in  jets  during  the  sexual  orgasm,  probably  through 
the  spasmodic  action  of  the  perineal  muscles.  At  other  times  their 
secretion  serves  the  purpose  of  lubricating  the  vulva,  and  thus  pre- 
serves the  sensibility  of  its  mucous  membrane. 

Fossa  Navicularis. — Immediately  behind  the  hymen  in  the  unmar- 
ried, and  between  it  and  the  perineum,  is  a  small  depression,  called  the 
fossa  naviculans,  which  disappears  after  childbearing. 

The  perineum  separates  the  orifice  of -the  vagina  from  that  of  the 
reo-tiim.  It  is  about  one  and  a  half  inches  in  breadth,  and  is  of  great 
obstetric  interest,  not  only  as  supporting  the  internal  organs  from 
!>rlow,  but  because  of  its  action  in  labor.  It  is  largely  stretched  and 
distended  by  the  presenting  part  of  the  child,  and,  if  unusually  tough 
and  unyielding,  may  retard  delivery,  or  it  may  be  torn  to  a  greater  or 
less  extent,  thus  giving  rise  to  various  subsequent  troubles. 

Vascular  Supply  of  the  Vulva. — The  structures  described  above 
together  form  the  vulva,  and  they  are  remarkable  for  their  abundant 
vascular  and  nervous  supply.  The  former  constitutes  an  erectile  tissue, 
similar  to  that  which  has  already  been  described  in  the  clitoris,  and 
which  is  specially  marked  about  the  bulb  of  the  vestibule.  From 
this  point,  and  extending  on  either  side  of  the  vagina,  there  is  a  well- 
marked  plexus  of  convoluted  veins  (Fig.  15,  a),  which,  in  their  dis- 
tended state,  are  likened  by  Dr.  Arthur  Farre  to  a  filled  leech.  The 
distention  of  the  erectile  tissue,  as  well  as  that  of  the  clitoris,  is  brought 


54 


ORGANS    CONCERNED    IN    PARTURITION. 


about  under  excitement,  as  in  the  male,  by  the  compression  of  the 
efferent  veins,  by  the  contraction  of  the  ischio-cavernous  muscles,  and 
by  that  of  a  thin  layer  of  muscular  tissues  surrounding  the  orifice  of  the 
vagina,  and  described  as  the  constrictor  vaginae. 


FIG.  15. 


Vascular  supply  of  vulva,  a.  Plexus  of  convoluted  veins  (or  "the  bulb"),  b.  Muscular  tissue 
of  vagina,  c,  d,  e,f.  The  clitoris  (/}  and  muscles,  g,  h.  i,  k,  I,  m,  n.  Veins  of  the  nymphae  and 
clitoris  communicating  with  the  epigastric  and  obturator  veins.  (After  KOBELT.) 

The  vagina  is  the  canal  which  forms  the  communication  between 
the  external  and  internal  generative  organs,  through  which  the  semen 
passes  to  reach  the  uterus,  the  menses  flow,  and  the  foetus  is  expelled. 
Roughly  speaking,  it  lies  in  the  axis  of  the  pelvis,  but  its  opening  is 
placed  anterior  to  the  axis  of  the  pelvic  outlet,  so  that  its  lower  portion 
is  curved  forward,  so  as  to  lie  parallel  to  the  pelvic  brim.  It  is  narrow 
below,  but  dilated  above,  where  the  cervix  uteri  is  inserted  into  it,  so 
that  it  is  more  or  less  couoidal  in  shape.  Under  ordinary  circum- 
stances, especially  in  the  virgin,  the  anterior  and  posterior  walls  lie  in 
close  contact  with  each  other  (see  Plate  I.),  and  there  is,  strictly  speak- 
ing, no  vaginal  canal,  although  they  are  capable  of  wide  distention,  as 
in  copulation,  and  during  the  passage  of  the  foetus.  The  anterior  wall 
of  the  vagina  is  shorter  than  the  posterior,  the  former  measuring  on  an 
average  two  and  a  half  inches,  the  latter  three  inches ;  but  the  length 
of  the  canal  varies  greatly  in  different  subjects  and  under  certain  cir- 
cumstances. In  front  the  vagina  is  closely  connected  with  the  base  of 
the  bladder,  so  that  when  the  vagina  is  prolapsed,  as  often  occurs,  it 
drags  the  bladder  with  it  (Fig.  17)  ;  behind,  it  is  in  relation  with  the 
rectum,  but  less  intimately  ;  laterally,  with  the  broad  ligaments  and 
pelvic  fascia ;  and  superiorly,  with  the  lower  portion  of  the  uterus  and 


THE  FEMALE  GENERATIVE  ORGANS. 


55 


folds  of  peritoneum  both  before  and  behind.  The  vagina  is  composed 
of  mucous,  muscular,  and  cellular  coats.  The  mucous  lining  is  thrown 
into  numerous  folds.  These  start  from  longitudinal  ridges  which  exist 
on  both  the  anterior  and  posterior  walls,  but  most  distinctly  on  the 
anterior.  They  are  very  numerous  in  the  young  and  unmarried,  and 
greatly  increase  the  sensitive  surface  of  the  vagina  (Fig.  16).  After 
childbearing,  and  in  the  aged,  tfyey  become  atrophied,  but  they  never 
completely  disappear,  and  toward  the  orifice  of  the  vagina,  where  they 
exist  in  greatest  abundance,  they  are  always  to  be  met  with.  The 
whole  of  the  mucous  membrane  is  lined  with  tessellated  epithelium, 
and  it  is  covered  with  a  large  number  of  papillae,  either  conical  or 
divided,  which  are  highly  vascular  and  project  into  the  epithelial  layer. 
Unlike  the  vulvar  mucous  membrane,  that  of  the  vagina  seems  to  be 

FIG.  16. 


Right  half  of  virgin  vagina,  with  walls  held  apart,  showing  the  abundant  transverse  rugse,  the 
greater  depth  of  the  vagina  above  than  below,  and  the  hymeneal  segment.    (After  HART.) 

destitute  of  glands.  Beneath  the  epithelial  layer  is  a  submucous  tissue 
containing  a  large  number  of  elastic  and  some  muscular  fibres,  derived 
from  the  muscular  walls  of  the  vagina.  These  are  strong  and  well  de- 
veloped, especially  toward  the  ostium  vaginae,  where  they  are  arranged 
in  a  circular  mass,  having  a  sphincter  action.  They  consist  of  two 
layers — an  internal  longitudinal,  and  an  external  circular — with  oblique 
decussating  fibres  connecting  the  two.  Below  they  are  attached  to  the 
ischio-pubic  rami,  and  above  they  are  continuous  with  the  muscular 
coat  of  the  uterus.  The  muscular  tissue  of  the  vagina  increases  in 
thickness  during  pregnancy,  but  to  a  much  less  degree  than  that  of  the 
uterus.  Its  vascular  arrangements,  like  those  of  the  vulva,  are  such 
as  to  constitute  an  erectile  tissue.  The  arteries  form  an  intricate  net- 
work around  the  tube,  and  eventually  end  in  a  submucous  capillary 
plexus  from  which  twigs  pass  to  supply  the  papillae  ;  these,  again,  give 
origin  to  venous  radicles  which  unite  into  meshes  freely  interlacing 
with  each  other,  and  forming  a  well-marked  venous  plexus. 


56 


ORGANS    CONCERNED    IN    PARTURITION, 


FIG.  17. 


Longitudinal  section  of  body,  showing  relations  of  generative  organs. 


FIG.  18. 


Transverse  section  of  the  body,  showing  relations  of  the  fundus  uteri,  m.  Pubes.  o  a  (in  front). 
Remainder  of  hypogastric  arteries,  a  a  (behind).  Spermatic  vessels  and  nerves.  B.  Bladder. 
L  L.  Round  ligaments.  U.  Fundus  uteri.  1 1.  Fallopian  tubes,  o  o.  Ovaries,  r.  Rectum. 
g.  Right  ureter,  resting  on  the  psoas  muscle,  c.  Utero-sacral  ligaments,  r.  Last  lumbar  vertebra. 


THE  FEMALE  GENERATIVE  ORGANS.          57 

2.  The  internal  organs  of  generation  consist  of  the  uterus,  the  Fallo- 
pian tubes,  and  the  ovaries ;  and  in  connection  with  them  we  have  to 
study  the  various  ligaments  and  folds  of  peritoneum  which  serve  to 
maintain  the  organs  in  position,  along  with  certain  accessory  struc- 
tures. Physiologically,  the  most  important  of  all  the  generative  organs 
are  the  ovaries,  in  which  the  ovules  are  formed,  and  which  dominate 
the  entire  reproductive  life  of  the  female.  The  Fallopian  tubes,  which 
convey  the  ovule  to  the  uterus,  and  the  uterus  itself — whose  main 
function  is  to  receive,  nourish,  and  eventually  expel  the  impregnated 
product  of  the  ovary — may  be  said  to  be,  in  fact,  accessory  to  these 
viscera.  Practically,  however,  as  obstetricians,  we  are  chiefly  con- 
cerned with  the  uterus,  and  may  conveniently  commence  with  its 
description. 

The  uterus  is  correctly  described  as  a  pyriform  organ,  flattened 
from  before  backward,  consisting  of  the  body,  with  its  rounded  fundus, 
and  the  cervix,  which  projects  into  the  upper  part  of  the  vaginal  canal. 
In  the  adult  female  it  is  deeply  situated  in  the  pelvis,  being  placed 
between  the  bladder  in  front  and  the  rectum  behind,  its  fundus  being 
below  the  plane  of  the  pelvic  brim  (Fig.  18).  It  only  assumes  this 
position,  however,  toward  the  period  of  puberty ;  and  in  the  fcetus  it 
is  placed  much  higher,  and  lies,  indeed,  entirely  within  the  cavity  of 
the  abdomen.  It  is  maintained  in  this  position  partly  by  being  slung 
by  its  ligaments,  which  we  shall  subsequently  study,  and  partly  by 
being  supported  from  below  by  the  pelvic  cellular  tissue  and  the  fleshy 
column  of  the  vagina.  The  result  is  that  the  uterus,  in  the  healthy 
female,  is  a  perfectly  movable  body,  altering  its  position  to  suit  the 
condition  of  the  surrounding  viscera,  especially  the  bladder  and  rectum, 
which  are  subjected  to  variations  of  size  according  to  their  fulness  or 
emptiness.  When  from  any  cause  the  mobility  of  the  organ  is  inter- 
fered with — as,  for  example,  by  some  peri-uterine  inflammation  produ- 
cing adhesions  to  the  surrounding  textures — much  distress  ensues,  and 
if  pregnancy  supervenes  more  or  less  serious  consequences  may  result. 
( iciicrally  speaking,  the  uterus  may  be  said  to  lie  in  a  line  roughly 
corresponding  with  the  axis  of  the  pelvic  brim,  its  fundus  being 
pointed  forward  and  its  cervix  lying  in  such  a  direction  that  a  line 
drawn  from  it  would  impinge  on  the  junction  between  the  sacrum  and 
coccyx.  According  to  some  authorities,  the  uterus  in  early  life  is  more 
curved  in  the  anterior  direction,  and  is,  in  fact,  normally  in  a  state  of 
anteflexion.  Sappey  holds  that  this  is  not  necessarily  the  case,  but 
that  the  amount  of  anterior  curvature  depends  on  the  emptiness  or 
fulness  of  the  bladder,  on  which  the  uterus,  as  it  were,  moulds  itself 
in  the  unimpregnated  state.  '  It  is  believed  also  that  the  body  of  the 
uterus  is  very  generally  twisted  somewhat  obliquely,  so  that  its  anterior 
surface  looks  a  little  toward  the  right  side,  this  probably  depending 
on  the  presence  and  frequent  distention  of  the  rectum  in  the  left  side 
of  the  pelvis.  The  anterior  surface  of  the  uterus  is  convex,  and  is 
covered  in  three-fourths  of  its  extent  by  the  peritoneum  which  is  inti- 
mately adherent  to  it.  Below  the  reflection  of  the  membrane  it  is 
loosely  connected  by  cellular  tissue  to  the  bladder,  so  that  any  down- 
ward displacement  of  the  uterus  drags  the  bladder  along  with  it.  The 


58 


ORGANS    CONCERNED    IN    PARTURITION. 


posterior  surface  is  also  convex,  but  more  distinctly  so  than  the  anterior, 
as  may  be  observed  in  looking  at  a  transverse  section  of  the  organ 
(Fig.  19).  It  is  also  covered  by  peritoneum,  the  reflection  of  which 
on  the  rectum  forms  the  cavity  known  as  Douglas's  pouch.  The 
fuudus  is  the  upper  extremity  of  the  uterus,  lying  above  the  points  of 
entry  of  the  Fallopian  tubes.  It  is  only  slightly  rounded  in  the 


FIG.  19. 


Transverse  section  of  uterus. 

virgin,  but  becomes  more  decidedly  and  permanently  rounded  in  the 
woman  who  has  borne  children. 

Until  the  period  of  puberty  the  uterus  remains  small  and  unde- 
veloped (Fig.  20)  ;  after  that  time  it  reaches  the  adult  size,  at  which  it 
remains  until  menstruation  ceases,  when  it  again  atrophies.  If  the 
woman  has  borne  children,  it  always  remains  larger  than  in  the 


Uterus  and  appendages  in  an  infant.    (After  FARRE.) 


nullipara.  In  the  virgin  adult  the  uterus  measures  2J  inches  from 
the  orifice  to  the  fundus,  rather  more  than  half  being  taken  up  by  the 
cervix.  Its  greatest  breadth  is  opposite  the  insertion  of  the  Fallopian 
tubes;  its  greatest  thickness,  about  11  or  12  lines,  opposite  the  centre 
of  its  body.  Its  average  weight  is  about  9  or  10  drachms.  Indepen- 


THE  FEMALE  GENERATIVE  ORGANS  59 

clcntly  of  pregnancy,  the  uterus  is  subject  to  great  alterations  of  size 
toward  the  menstrual  period,  when,  on  account  of  the  congestion  then 
present,  it  enlarges — sometimes,  it  is  said,  considerably.  This  fact 
should  be  borne  in  rnind,  as  this  periodical  swelling  might  be  taken 
for  an  early  pregnancy. 

For  the  purpose  of  description  the  uterus  is  conveniently  divided  into 
the  fundus,  with  its  rounded  upper  extremity,  situated  between  the  in- 
sertions of  the  Fallopian  tubes ;  the  body,  which  is  bounded  above  by 
the  insertions  of  the  Fallopian  tubes,  and  below  by  the  upper  extremity 
of  the  cervix,  and  which  is  the  part  chiefly  concerned  in  the  reception 
and  growth  of  the  ovum  ;  and  the  cervix,  which  projects  into  the  vagina, 
and  dilates  during  labor  to  give  passage  to  the  child.  The  cervix  is 
conical  in  shape,  measuring  11  to  12  lines  transversely  at  the  base, 
and  6  or  7  in  the  antero-posterior  direction ;  while  at  the  apex  it 
measures  7  to  8  transversely,  and  5  antero-posteriorly.  It  projects 
about  4  lines  into  the  canal  of  the  vagina,  the  remainder  of  the  cervix 
being  placed  above  the  reflection  of  the  vaginal  mucous  membrane. 
It  varies  much  in  form  in  the  virgin  and  nulliparous  married  woman, 
and  in  the  woman  who  has  borne  children  ;  and  the  differences  are  of 
importance  in  the  diagnosis  of  pregnancy  and  uterine  disease.  In  the 
virgin  it  is  regularly  pyramidal  in  shape.  At  its  lower  extremity  is 
the  opening  of  the  external  os  uteri,  forming  a  small  circular  opening, 
sometimes  difficult  to  feel,  and  generally  described  as  giving  a  sensa- 
tion to  the  examining  finger  like  the  extremity  of  the  cartilage  at  the 
tip  of  the  nose.  It  is  bounded  by  two  lips,  the  anterior  of  which  is 
apparently  larger  on  account  of  the  position  of  the  uterus.  The  sur- 
face of  the  cervix  and  the  borders  of  the  os  are  very  smooth  and 
regular. 

In  women  who  have  borne  children  these  parts  become  considerably 
altered.  The  cervix  is  no  longer  conical,  but  is  irregular  in  form  and 
shortened.  The  lips  of  the  os  uteri  become  fissured  and  lobulated,  on 
account  of  partial  lacerations  which  have  occurred  during  labor.  The 
os  is  larger  and  more  irregular  in  outline,  and  is  sometimes  sufficiently 
putulous  to  admit  the  tip  of  the  finger.  In  old  age  the  cervix  atro- 
phies, and  after  the  change  of  life  it  not  uncommonly  entirely  dis- 
appears, so  that  the  orifice  of  the  os  uteri  is  on  a  level  with  the  roof 
of  the  vagina. 

The  internal  surface  of  the  uterus  comprises  the  cavities  of  the  body 
and  cervix — the  former  being  rather  less  than  the  latter  in  length  in 
virgins,  but  about  equal  in  women  who  have  borne  children — separated 
from  each  other  by  a  constriction  forming  the  upper  boundary  of  the 
cervical  canal.  The  cavity  of  the  body  is  triangular  in  shape,  the  base 
of  the  triangle  being  formed  by  a  line  joining  the  openings  of  the 
Fallopian  tubes,  its  apex  by  the  upper  orifice  of  the  cervix,  or  internal 
os,  as  it  is  sometimes  called.  In  the  virgin  its  boundaries  are  some- 
what convex,  projecting  inward.  After  childbearing  they  become 
straight  or  slightly  concave.  The  opposing  surfaces  of  the  cavity  are 
always  in  contact  in  the  healthy  state,  or  are  only  separated  from  each 
other  by  a  small  quantity  of  mucus. 

The  cavity  of  the  cervix  is  spindle-shaped  or  fusiform,  narrower 


60 


ORGANS    CONCERNED    IN    PARTURITION. 


above  and  below,  at  the  internal  and  external  os  uteri,  and  somewhat 
dilated  between  these  two  points.  It  is  flattened  from  before  back- 
ward, and  its  opposing  surfaces  also  lie  in  contact,  but  not  so  closely 
as  those  of  the  body.  On  the  mucous  lining  of  the  anterior  and  pos- 
terior surfaces  is  a  prominent  perpendicular  ridge,  with  a  lesser  one  at 
each  side,  from  which  transverse  ridges  proceed  at  more  or  less  acute 
angles.  They  have  received  the  name  of  the  arbor  vitce.  According 
to  Guyon,  the  perpendicular  ridges  are  not  exactly  opposite,  so  that 
they  fit  into  each  other,  and  serve  more  completely  to  fill  up  the  cavity 
of  the  cervix,  especially  toward  the  internal  os  (Fig.  21).  The  arbor 
vitse  is  most  distinct  in  the  virgin,  and  atrophies  considerably  after 
childbearing. 


Portion  of  interior  of  cervix.    (Enlarged  nine  diameters.)    (.After  TVLEK  SMITH  and  HASSALL.) 


The  superior  extremity  of  the  cervical  canal  forms  a  narrow  isthmus 
separating  it  from  the  cavity  of  the  body,  and  measuring  about  three- 
eighths  of  an  inch  in  diameter.  Like  the  external  os,  it  contracts  after 
the  cessation  of  menstruation,  and  in  old  age  sometimes  becomes  en- 
tirely obliterated. 

The  uterus  is  composed  of  three  principal  structures — the  peritoneal, 
muscular,  and  mucous  coats.  The  peritoneum  forms  an  investment  to 
the  greater  part  of  the  organ,  extending  downward  in  front  to  the 
level  of  the  os  internum,  and  behind  to  the  top  of  the  vagina,  from  which 
points  it  is  reflected  upward  on  the  bladder  and  rectum  respectively. 
At  the  sides  the  peritoneal  investment  is  not  so  extensive,  for  a  little 
below  the  level  of  the  Fallopian  tubes  the  peritoneal  folds  separate 
from  each  other,  forming  the  broad  ligaments  (to  be  afterward  de- 
scribed) ;  here  it  is  that  the  vessels  and  nerves  supplying  the  uterus 


THE  FEMALE  GENERATIVE  ORGANS. 


61 


FIG.  22. 


gain  access  to  it.  At  the  upper  part  of  the  organ  the  peritoneum  is 
so  closely  adherent  to  the  muscular  tissue  that  it  cannot  be  separated 
from  it ;  below  the  connection  is  more  loose.  The  mass  of  the  uterine 
tissue,  both  in  the  body  and  cer- 
vix, consists  of  unstriped  muscu- 
lar fibres  (Fig.  22),  firmly  united 
together  by  nucleated  connective 
tissue  and  elastic  fibres.  The  mus- 
cular fibre  cells  are  large  and  fusi- 
form, with  very  attenuated  extremi- 
ties, generally  containing  in  their 
centre  a  distinct  nucleus.  These 
cells,  as  well  as  their  nuclei,  become 
greatly  enlarged  during  pregnancy 
(Fig.  23);  according  to  Strieker, 
this  is  only  the  case  with  the  mus- 
cular fibres  which  play  an  important  part  in  the  expulsion  of  the 
foetus,  those  of  the  outermost  and  innermost  layers  not  sharing  in  the 
increase  of  size.1  In  addition  to  these  developed  fibres  there  are, 
especially  near  the  mucous  coat,  a  number  of  round  elementary  cor- 
puscles, which  are  believed  by  Dr.  Farre2  to  be  the  elementary  form 
of  the  muscular  fibres,  and  which  he  has  traced  in  various  intermediate 
states  of  development.  Dr.  John  Williams3  believes  that  a  great  part 


Muscular  fibres  of  unimpregnated  uterus, 
a.  Fibres  united  by  connective  tissue,  b. 
Separate  fibres  and  elementary  corpuscles. 
(After  FARRE.) 


FIG.  2?. 


Developed  muscular  fibres  from  the  gravid  uterus.    (After  WAGNER.) 

of  the  muscular  tissue  of  the  uterus,  rather  more  indeed  than  three- 
fourths  of  its  thickness,  is  an  integral  part  of  the  mucous  membrane, 
analogous  to  the  muscularis  mucosse  of  the  mucous  membrane  of  the 
alimentary  canal.  This  he  describes  as  being  separated  from  the  rest 
of  the  muscular  tissue  by  a  layer  of  rather  loose  connective  tissue, 
containing  numerous  vessels.  In  early  foetal  life,  and  in  the  uteri  of 
some  of  the  lower  animals,  this  appearance  is  very  distinct ;  in  the 
adult  female  uterus,  however,  it  can  be  readily  made  out. 

On  examining  the  uterine  tissue  in  an  unimpregnated  condition,  no 
definite  arrangement  of  its  muscular  fibres  can  be  made  out,  and  the 
whole  seemed  blended  in  inextricable  confusion.  By  observation  of 

1  Comparative  Histology,  vol.  iii.  ;  Syd.  Soc.  Trans.,  p.  477. 

2  The  Uterus  and  its  Appendages,  p.  632. 

8  "On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,"  Obstet.  Journ.,  1875-6,  vol.  in.  p. 
496. 


62  ORGANS    CONCERNED    IN    PARTURITION. 

their  relations  when  hypertrophied  during  pregnancy,  Helie1  has 
shown  that  they  may,  speaking  roughly,  be  divided  into  three  layers : 
an  external ;  a  middle,  chiefly  longitudinal ;  and  an  internal,  chiefly 
circular.  Into  the  details  of  their  distribution,  as  described  by  him, 
it  is  needless  to  enter  at  length.  Briefly,  however,  he  describes  the 
external  layer  as  arising  posteriorly  at  the  junction  of  the  body  and 
cervix,  and  spreading  upward  and  over  the  fimdus.  From  this  are 
derived  the  muscular  fibres  found  in  the  broad  and  round  ligaments, 
and  more  particularly  described  by  Rouget.  The  middle  layer  is 
made  up  of  strong  fasciculi,  which  run  upward,  but  decussate  and 
unite  with  each  other  in  a  remarkable  manner,  so  that  those  which 
are  at  first  superficial  become  most  deeply  seated,  and  vice  versa.  The 
muscular  fasciculi  which  form  this  coat  curve  in  a  circular  manner 
round  the  large  veins,  so  as  to  form  a  species  of  muscular  canal 

FIG,  24. 


From  the  body.        From  orifice  of  Fallopian  tube. 

Lining  membrane  of  uterus,  showing  network  of  capillaries  and  orifices  of  uterine  glands. 

(After  FARKE.) 

through  which  they  run.  This  arrangement  is  of  peculiar  importance, 
as  it  affords  a  satisfactory  explanation  of  the  mechanism  by  which 
hemorrhage  after  delivery  is  prevented.  The  internal  layer  is  mainly 
composed  of  circular  rings  of  muscular  fibres,  beginning  around  the 
openings  of  the  Fallopian  tubes,  and  forming  wider  and  wider  circles 
which  eventually  touch  and  interlace  with  each  other.  They  surround 
the  internal  os,  to  which  they  form  a  kind  of  sphincter.  In  addition 
to  these  circular  fibres  on  the  internal  uterine  surface  both  anteriorly 
and  posteriorly,  there  is  a  well-marked  triangular  layer  of  longitudinal 
fibres,  the  base  being  above  and  the  apex  below,  which  sends  muscular 
fasciculi  into  the  mucous  membrane. 

The  anatomy  of  the  lining  membrane  of  the  uterus  has  been  the 
subject  of  considerable  discussion.  Its  existence  has  been  denied  by 
many  authorities,  most  recently  by  Snow  Beck,2  who  maintains  that  it 
is  in  no  sense  a  mucous  membrane,  but  only  a  softened  portion  of  true 
uterine  tissue.  It  is,  however,  pretty  generally  admitted  by  the  best 
authorities  that  it  is  essentially  a  mucous  membrane,  differing  from 
others  only  in  being  more  closely  adherent  to  the  subjacent  struc* 
tures,  in  consequence  of  not  possessing  any  definite  connective-tissue 
framework. 

It  is  a  pale  pink  membrane  of  considerable  thickness,  most  marked 

i  Recherches  sur  la  Disposition  des  Fibres  musculaires  de  1'Uterus.    Paris,  1869. 
*  Obstet.  Trans.,  1872,  vol.  xiii.  p.  294. 


THE  FEMALE  GENERATIVE  ORGANS. 


63 


FIG.  25. 


at  the  centre  of  the  body,  where  it  forms  from  one-eighth  to  one-fourth 
of  the  thickness  of  the  whole  uterine  walls.     At  the  internal  os  uteri 
it  terminates  by  a   distinct   border,  which 
separates  it   from    the    mucous    membrane 
lining  the  cervical  cavity. 

On  the  surface  of  the  mucous  membrane 
may  be  observed  a  multitude  of  little  open- 
ings, about  one-thirtieth  of  a  line  in  width 
(Fig.  24).  These  are  the  orifices  of  the 
titricular  glands,  which  are  found  in  im- 
mense numbers  all  over  the  cavity  of  the 
uterus,  and  very  closely  agglomerated  to- 
gether. They  are  little  cul-de-sacs,  nar- 
rower at  their  mouths  than  in  their  length, 
the  blind  extremities  of  which  are  found  in 
the  subjacent  tissues  (Fig.  26).  Williams 
describes  them  as  running  obliquely  toward 
the  surface  at  the  lower  third  of  the  cavity, 
perpendicularly  at  its  middle,  while  toward 
the  fundus  they  are  at  first  perpendicular, 
and  then  oblique  in  their  course  (Fig.  25). 
By  others  they  are  described  as  being  often 
twisted  and  corkscrew-like.  One  or  more 
may  unite  to  form  a  common  orifice,  several 
of  which  may  open  together  in  little  pits  or 
depressions  on  the  surface  of  the  mucous 
membrane.  These  glands  are  composed  of 
structureless  membrane  lined  with  epithe- 
lium, the  precise  character  of  which  is 
doubtful.  By  some  it  is  described  as  co- 
lumnar, by  others  as  tessellated,  and  by  some 
again  as  ciliated.  The  most  generally  re- 
ceived opinion  is  that  it  is  columnar,  but  not 
ciliated;  therein  differing  from  the  epithe- 
lium covering  the  surface  of  the  membrane,  which  is  undoubtedly 
ciliated,  the  movements  of  the  cilia  being  from  within  outward. 
Williams,  however,  has  observed  cilia  in  active  movement  on  the 
columnar  epithelium  lining  the  glands,  and  also  states  that  at  the 
deep-seated  extremities  of  the  glands,  which  penetrate  between  the 
muscular  fibres  for  some  distance,  the  columnar  epithelium  is  replaced ' 
by  rounded  cells.  The  capillaries  of  the  mucous  membrane  run  down 
between  the  tubes,  forming  a  lacework  on  their  surfaces,  and  around 
their  orifices.  No  true  papilla  exist  in  the  membrane  lining  the 
uterine  cavity.  The  mucous  membrane  of  the  uterus  is  peculiar  in 
being  always  in  a  state  of  change  and  alteration,  being  thrown  off  at 
each  menstrual  period  in  the  form  of  dSbris,  in  consequence  of  fatty 
degeneration  of  its  structures,  and  re-formed  afresh  by  proliferation  of 
the  cells  of  the  muscular  and  connective  tissues,  probably  from  below 
upward,  the  new  membrane  commencing  at  the  internal  os.  Hence 
its  appearance  and  structure  vary  considerably  according  to  the  time  at 


The  course  of  the  glands  in  the 
fully  developed  mucous  mem- 
brane of  the  uterus,  viz.,  just 
before  the  onset  of  a  menstrual 
period.  (After  WILLIAMS.) 


64 


ORGANS    CONCERNED    IN    PARTURITION, 


which  it  is  examined.     The  subject,  however,  will  be  more  particularly 
studied  in  connection  with  menstruation. 

The  mucous  membrane  of  the  cervix  is  much  thicker  and  more 
transparent  than  that  of  the  body  of  the  uterus,  from  which  it  also 
differs  in  certain  structural  peculiarities.  The  general  arrangements 
of  its  folds  and  surface  have  already  been  described.  The  lower  half 
of  the  membrane  lining  the  cavity  of  the  cervix,  and  the  whole  of 
that  covering  its  external  or  vaginal  portion,  are  closely  set  with  a 
large  number  of  minute  filiform,  or  clavate  papillae  (Fig.  27).  Their 


Vertical  section  through  the  mucous  membrane  of  the  human  uterus,  e.  Columnar  epithelium ; 
the  cilia  are  not  represented,  g  g.  Utricular  glands,  ct  ct.  Interglandular  connective  tissue,  v  v. 
Bloodvessels,  m  m.  Muscularis  mucosse.  (After  TURNER.) 

structure  is  similar  to  that  of  the  mucous  membrane  itself,  of  which 
they  seem  to  be  merely  elevations.  They  each  contain  a  vascular  loop 
(Fig.  28),  and  they  are  believed  by  Kilian  and  Farre  to  be  mainly 
concerned  in  giving  sensibility  to  this  part  of  the  generative  tract. 
All  over  the  interior  of  the  cervix,  both  on  the  ridges  of  the  mucous 
membrane  and  between  their  folds,  are  a  very  large  number  of  mucous 
follicles  consisting  of  a  structureless  membrane  lined  with  cylindrical 
epithelium,  and  intimately  united  with  connective  tissue.  They  cease 
at  the  external  orifice  of  the  cervix,  and  they  secrete  the  thick,  tena- 
cious, and  alkaline  mucus  which  is  generally  found  filling  the  cervical 
cavity.  The  transparent  follicles,  known  as  the  ovula  Nabothii, 
which  are  sometimes  found  in  considerable  numbers  in  the  cavity  of 
the  cervix,  consist  of  mucous  follicles  the  mouths  of  which  have 


THE  FEMALE  GENERATIVE  ORGANS. 


65 


FIG.  27. 


Villi  of  os  uteri  stripped  of  epithelium.    (After  TYLER  SMITH  and  HASSALL.) 


FIG.  28. 


Villi  of  uterus,  covered  with  pavement  epithelium  and  containing  looped 
TYLER  SMITH  and  HASSALL.) 


(After 


66  ORGANS    CONCERNED    IN    PARTURITION. 

become  obstructed,  and  their  canals  distended  by  mucous  secretion.  The 
lower  third  of  the  cervical  canal,  as  well  as  the  exterior  of  the  cervix, 
is  covered  with  pavement  epithelium  ;  while  on  its  upper  portion  is 
found  a  columnar  and  ciliated  epithelium  similar  to  that  lining  the 
uterine  cavity. 

Bandl1  describes  the  cervical  mucous  membrane  as  extending  much 
higher  in  the  virgin  than  in  women  who  have  borne  children,  being 
traceable  in  the  former  nearly  to  the  middle  of  the  body  of  the  uterus. 
During  the  first  pregnancy  he  believes  that  the  upper  portion  of  the 
cervix  is  taken  up  into  the  body  of  the  uterus,  its  mucous  membrane 
never  regaining  the  arrangement  peculiar  to  that  of  the  cervical  canal. 

The  arteries  of  the  uterus  are  derived  from  the  internal  iliac  and 
from  the  ovarian.  They  enter  the  uterus  between  the  folds  of  the 
broad  ligaments,  and,  penetrating  its  muscular  coat,  anastomose  freely 
with  each  other  and  with  the  corresponding  vessels  of  the  opposite 
side.  They  are  described  by  Williams2  as  entering  the  uterus  on  its 
sides  and  then  running  a  somewhat  superficial  course,  being  separated 
from  the  peritoneum  by  a  thin  layer  of  muscular  fibres.  They  are 
here  placed  in  a  distinct  layer  of  connective  tissue,  and  give  oft 
branches  which  pass  perpendicularly  toward  the  uterine  canal.  Their 
walls  are  thick  and  well  developed,  and  they  are  remarkable  for  their 
very  tortuous  course,  forming  spiral  curves,  especially  in  the  upper 
part  of  the  uterus.  They  end  in  minute  capillaries  which  form  the 
fine  meshes  surrounding  the  glands,  and  in  the  cervix  give  oif  the 
loops  entering  the  papillae.  Beneath  the  uterine  mucous  membrane 
these  capillaries  form  a  plexus,  terminating  in  veins  without  valves, 
which  unite  with  each  other  to  form  the  large  veins  traversing  the 
substance  of  the  uterus,  known  during  pregnancy  as  the  uterine 
sinuses,  the  walls  of  which  are  closely  adherent  to  the  uterine  tissues. 
These  veins  run  a  similar  course  to  the  arteries,  and  end  in  a  venous 
plexus  lying  in  the  layer  of  connective  tissue  already  mentioned,  which 
Williams  believes  to  be  the  true  submueous  tissue  of  the  uterus,  the 
thick  layer  of  muscular  tissue  between  it  and  the  uterine  cavity  being 
really  "  muscularis  mucosse."  In  consequence  of  this  arrangement  the 
circulation  of  the  uterus  can  hardly  be  disturbed  by  mechanical  causes. 
The  veins,  freely  anastomosing  with  each  other,  pass  from  the  uterus 
to  the  folds  of  the  broad  ligaments,  where  they  unite  to  form,  M*ith  the 
ovarian  and  vaginal  veins,  a  large  and  well-developed  venous  network, 
known  as  the  pampiniform  plexus. 

The  lymphatics  of  the  uterus  are  large  and  well  developed,  and  they 
have  recently,  and  with  much  probability,  been  supposed  to  play  an 
important  part  in  the  production  of  certain  puerperal  diseases.  A 
more  minute  knowledge  than  we  at  present  possess  of  their  course  and 
distribution  will  probably  throw  much  light  on  their  influence  in  this 
respect.  According  to  the  researches  of  Leopold,3  who  has  studied 
their  minute  anatomy  carefully,  they  originate  in  lymph  spaces  between 
the  fine  bundles  of  connective  tissue  forming  the  basis  of  the  mucous 


1  Arch.  f.  Gynak.,  1879,  Bd.  xiv.,  S.  237. 

2  Trans.  Ohst,  Society,  1885,  vol.  xxvii.  p.  1 
«  Arch.  f.  Gynak.,  1873,  Bd.  vi.,  Heft  1,8.1. 


THE  FEMALE  GENERATIVE  ORGANS.          67 

lining  of  the  uterus.  Here  they  arc  in  intimate  contact  with  the 
utricular  glands  and  the  ultimate  ramifications  of  the  uterine  blood- 
vessels. As  they  pass  into  the  muscular  tissue  they  become  gradually 
narrowed  into  lymph-ve'ssels  and  spaces,  which  have  a  very  compli- 
cated arrangement,  and  which  eventually  unite  together  in  the  external 
muscular  layer,  especially  on  the  sides  of  the  uterus,  to  form  large 
canals  which  probably  have  valves.  Immediately  under  the  perito- 
neum these  lymph-vessels  form  a  large  and  characteristic  network 
covering  the  anterior  and  posterior  surfaces  of  the  uterus,  and  present, 
in  various  parts  of  their  course,  large  ampulla?.  They  then  spread 
over  the  Fallopian  tubes.  The  lymphatics  of  the  body  of  the  uterus 
unite  with  the  lumbar  glands,  those  of  the  cervix  with  the  pelvic 
glands. 

The  distribution  and  arrangement  of  the  nerves  of  the  uterus  have 
been  the  subject  of  much  controversy.  They  are  derived  mainly  from 
the  ovarian  and  hypogastric  plexuses,  inosculating  freely  with  each  other 
between  the  folds  of  the  broad  ligament,  from  which  they  enter  the 
muscular  tissue  of  the  uterus,  generally,  but  not  invariably,  following 
the  course  of  the  arteries.  They  are  chiefly  derived  from  the  sympa- 
thetic ;  but,  as  the  hypogastric  plexus  is  connected  with  the  sacral 
nerves,  it  is  probable  that  some  fibres  from  the  cerebro-spinal  system 
are  distributed  to  the  cervix.  It  is  now  generally  admitted  that 
nervous  filaments  are  distributed  to  the  cervix,  even  as  far  as  the 
external  os,  although  their  existence  in  this  situation  has  been  denied 
by  Jobert  and  other  writers.  The  ultimate  distribution  of  the  nerves 
is  not  yet  made  out.  Polle  describes  a  nerve  filament  as  entering  the 
papilla?  of  the  cervical  mucous  membrane  along  with  the  capillary 
loop,  and  Frankenhauser  says  the  nerve  fibres  surround  the  muscles  of 
the  uterus  in  the  form  of  plexuses,  and  terminate  in  the  nuclei  of  the 
muscle  cells. 

Anomalies  of  the  Uterus. — Various  abnormal  conditions  of  tho 
uterus  and  vagina  are  occasionally  met  with,  which  it  is  necessary  to 


FIG.  29. 


Uiiid  uterus,    i  After  FARRE.) 


mention,  as  they  may  have  an  important  practical  bearing  on  parturition. 
The  most  frequent  of  these  is  the  existence  of  a  double,  or  partially 


68  ORGANS    CONCERNED    IN    PARTURITION. 

double  uterus  (Fig.  29),  similar  to  that  found  normally  in  many  of 
the  lower  animals.  This  abnormality  is  explained  by  the  development 
of  the  organ  during  foetal  life.  The  uterus  is  formed  out  of  struc- 
tures existing  only  in  early  foetal  life,  known  as  the  Wolffian  bodies. 
These  consist  of  a  number  of  tubes,  situated  on  either  side  of  the 
vertebral  column,  and  opening  externally  into  an  excretory  duct. 
Along  their  external  border  a  hollow  canal  is  formed,  termed  the  canal 
of  Miiller,  which,  like  the  excretory  ducts,  proceeds  to  the  common 
cloaca  of  the  digestive  and  urinary  organs  which  then  exists.  The 
canal  of  Miiller  unites  with  its  fellow  of  the  opposite  side  to  form  the 
uterus  and  Fallopian  tubes  in  the  female,  and  subsequently  the  central 
partition  at  their  point  of  junction  disappears.  If,  however,  the  pro- 
gress of  development  be  in  any  way  checked,  the  central  partition  may 
remain.  Then  we  have  produced  either  a  complete  double  uterus  or 
the  uterus  bicornis,  which  is  bifid  at  its  upper  extremity  only ;  or  a 
double  vagina,  each  leading  to  a  separate  uterus. 

If  pregnancy  occur  in  any  of  these  anomalous  uteri,  and  many  such 
cases  are  recorded,  serious  troubles  may  follow.  It  may  happen  that 
one  horn  of  the  double  uterus  is  not  sufficiently  large  to  admit  of  preg- 
nancy going  on  to  term,  and  rupture  may  occur.  It  is  supposed  that 
some  cases,  presumed  to  be  tubal  gestation,  are  really  thus  explicable. 
Impregnation  may  also  occur  in  the  two  cornua  at  different  times, 
leading  to  superfcetation.  It  is,  however,  quite  possible  that  impreg- 
nation may  occur  in  one  horn  of  a  bifid  uterus,  and  labor  be  com- 
pleted without  anything  unusual  being  observed.  A  remarkable  case 
of  this  sort  has  been  recorded  by  Dr.  Ross,  of  Brighton,1  in  which  a 
patient  miscarried  of  twins  on  July  16,  1870,  and  on  October  31st, 
fifteen  weeks  later,  she  was  delivered  of  a  healthy  child.  Careful 
examination  showed  the  existence  of  a  complete  double  uterus,  each 
side  of  which  had  been  impregnated.  Curiously  enough,  this  patient  had 
formerly  given  birth  to  six  living  children  at  term,  nothing  remark- 
able having  been  observed  in  her  labors.  It  can  only  rarely  happen 
that,  under  such  circumstances,  so  favorable  a  result  will  follow,  and 
more  or  less  difficulty  and  danger  may  generally  be  expected.  Occasion- 
ally the  vagina  only  is  double,  the  uterus  being  single.  Dr.  Matthews 
Duncan  has  recorded  some  cases  of  this  kind,2  in  which  the  vaginal  sep- 
tum formed  an  obstacle  to  the  birth  of  the  child,  and  required  division. 

[Double  uteri  are  of  several  distinct  types,  the  extremes  of  which  are 
the  "partitioned  uterus,"  where  the  organ  is  single  without,  and  double 
within,  and  the  "  completely  bifid  uterus,"  where  there  is  a  double 
vagina  and  cervix  with  a  Y-shaped  or  double-barrelled  body.  The 
former  can  only  be  diagnosticated  from  within  and  is  rarely  discovered 
until  after  the  second  stage  of  a  labor  has  been  completed.  In  a  case 
reported  by  Dr.  B.  F.  Baer,  of  Philadelphia,  the  patient  bore  twins, 
one  fetus  from  each  compartment,  the  birth  of  which  was  followed  by 
two  single  placentae  at  intervals  of  a  quarter  of  an  hour.  Where  there 
is  only  one  foetus  the  uterus  develops  mainly  on  one  side,  and  the 
unoccupied  one  lies  much  lower  than  the  fundus  of  the  other.  Dr. 

1  Lancet,  1871,  vol.  ii.  p.  188.  *  Researches  in  Obstetrics,  p.  443. 


THE  FEMALE  GENERATIVE  ORGANS. 


69 


I  )r,  sdale,  of  this  city,  discovered  one  such  case  by  the  touch  after 
labor,  and  no  doubt  a  careful  scrutiny  would  find  that  they  are  less 
rare  than  might  be  presumed. 

Where  one  side  of  a  bifid  uterus  is  impregnated,  the  unoccupied 
one  rotates  into  the  hollow  of  the  sacrum,  and  the  other  develops 
under  the  abdominal  wall,  The  sound  will  readily  enter  the  empty 
half  of  the  organ  in  the  median  line,  and  may  lead  to  an  error  in  diag- 
nosis, the  pregnancy  being  regarded  as  extra-uterine.  Very  skilful 
obstetricians  have  been  deceived  in  this  wav. 


Uterus  septus  uniformis.  a.  Vagina.  I.  tingle  ok  uteri,  c.  Partition  of  uterus,  thick  above  and 
thin  below  d  d.  Right  and  left  uterine  cavities,  e  e.  Two  ridges  in  the  posterior  wall  of  the 
cervix.  (From  KUSSMACL,  after  GRAVEL.) 

Pregnancy  in  a  aterus  unicornus  is  apt  to  terminate  fatally  by  rup- 
ture, but  exceptional  cases  may  occur  and  the  foetus  be  delivered  at 
term.  In  one  case  seen  by  the  writer  the  development  of  the  abnormal 
uterus  gave  rise  to  much  pain  and  distress  for  several  months,  and  an 
extra-uterine  pregnancy  was  regarded  as  almost  certain  by  the  family 
physician.  The  child  was  a  female  of  four  pounds,  and  died  in  three 
<lavs  from  an  undeveloped  duodenum  and  an  imperforate  rectum  :  the 
co run  was  on  the  right  side. — ED.] 

Ligaments  of  the  Uterus. — The  various  folds  of  peritoneum  which 
invest  the  uterus  serve  to  maintain  it  in  position,  and  they  are  described 
as  its  ligamerts.  They  are  the  broad,  the  vesico-uteriue,  and  sacro- 
utcrine  ligaments;  the  round  ligaments  are  not  peritoneal  folds  like 
the  others. 

The  broad  ligaments  extend  from  cither  side  of  the  uterus,  where 
their  laminas  are  separated  from  each  other,  transversely  across  to  the 


70 


ORGANS    CONCERNED    IN    PARTURITION. 


pelvic  wall,  and  thus  divide  the  cavity  of  the  pelvis  into  two  parts ; 
the  anterior  containing  the  bladder,  the  posterior  the  rectum.  Their 
upper  borders  are  divided  into  three  subsidiary  folds,  the  anterior  of 
which  contains  the  round  ligament,  the  middle  the  Fallopian  tube, 
and  the  posterior  the  ovary.  The  arrangement  has  received  the  name 
of  the  ala  vespertitionis,  from  its  fancied  resemblance  to  a  bat's  wing. 
Between  the  folds  of  the  broad  ligaments  are  found  the  uterine  vessels 
and  nerves,  and  a  certain  amount  of  loose  cellular  tissue  continuous 
with  the  pelvic  fascia?.  Here  is  situated  that  peculiar  structure  called 
the  organ  of  Rosenmiiller,  or  the  parovarium  (Fig.  31),  which  is  the 
remains  of  the  Wolffian  body,  and  corresponds  to  the  epididymis  in  the 
male.  This  may  best  be  seen  in  young  subjects,  by  holding  up  the 
broad  ligaments  and  looking  through  them  by  transmitted  light ;  but 
it  exists  at  all  ages.  It  consists  of  several  tubes  (eight  or  ten  according 

Fu.  31. 


\dult  parovarium,  ovary,  and  Fallopian  tube.    (After  KOBELT. 


to  Farre,  eighteen  or  twenty  according  to  Bankes1),  which  are  tortuous 
in  their  course.  They  are  arranged  in  a  pyramidal  form,  the  base  of 
the  pyramid  being  toward  the  Fallopian  tube,  its  apex  being  lost  on 
the  surface  of  the  ovary.  They  are  formed  of  fibrous  tissue,  and  lined 
with  pavement  epithelium.  They  have  no  excretory  duct  or  commu- 
nication with  either  the  uterus  or  ovary,  and  their  function,  if  they 
have  any,  is  unknown 

A  number  of  muscular  fibres  are  also  found  in  this  situation,  lying 
between  the  meshes  of  the  connective  tissue.  They  have  been  particu- 
larly studied  by  liouget,  who  describes  them  as  interlacing  with  each 
other,  and  forming  an  open  network,  continuous  with  the  muscular 
tissues  of  the  uterus  (Fig.  32).  They  are  divisible  into  two  layers,  the 
anterior  of  which  is  continuous  witli  the  muscular  fibres  of  the  anterior 
surface  of  the  uterus,  and  goes  to  form  part  of  the  round  ligament ; 
the  posterior  arises  from  the  posterior  wall  of  the  uterus,  and  proceeds 
transversely  outward,  to  become  attached  to  the  sacro-iliac  synchon- 
drosis.  A  continuous  muscular  envelope  is  thus  formed,  which  sur- 

i  Bankes :  On  the  Wolffian  Bodies. 


THE  FEMALE  GEXERATIVE  ORGANS. 


71 


rounds  the  whole  of  the  uterus,  Fallopian  tubes,  and  ovaries.  Its 
function  is  not  yet  thoroughly  established.  It  is  supposed  to  have  the 
effect  of  retracting  the  stretched  folds  of  peritoneum  after  delivery,  and 
more  especially  of  bringing  the  entire  generative  organs  into  harmoni- 
ous action  during  menstruation  and  the  sexual  orgasm ;  in  this  way 
explaining,  as  we  shall  subsequently  see,  the  mechanism  by  which  the 
fimbriated  extremity  of  the  Fallopian  tube  is  said  to  grasp  the  ovary 
prior  to  the  rupture  of  a  Graafian  follicle. 


Posterior  view  of  muscular  and  vascular  arrangements.  Vessels.— I,  2,  3.  Vaginal,  cervical,  ami 
uterine  plexuses.  4.  Arteries  of  body  of  uterus.  5.  Arteries  supplying  ovary.  Muscular  fasci- 
culi.—6,  7.  Fibres  attached  to  vagina,  symphysis  pubis,  and  sacro-iliac  joint.  8.  Muscular  fasiculi 
from  uterus  and  broad  ligaments.  9,  10, 11, 12.  Pasiculi  attached  to  ovary  and  Fallopian  tubes. 
(After  ROUGET.) 

The  round  ligaments  are  essentially  muscular  in  structure.  They 
extend  from  the  upper  border  of  the  uterus,  with  the  fibres  of  which 
their  muscular  fibres  are  continuous,  transversely,  and  then  obliquely 
downward,  until  they  reach  the  inguinal  rings,  where  they  blend  with 
the  cellular  tissue.  In  the  first  part  of  their  course  the  muscular 
fibres  are  .solely  of  the  unstriped  variety,  but  soon  they  receive  striped 
fibres  from  the  trans versalis  muscles,  and  the  columns  of  the  inguinal 
ring,  which  surround  and  cover  the  unstriped  muscular  tissue.  J  n 
addition  to  these  structures  they  contain  elastic  and  connective  tissue, 
and  arterial,  venous,  and  nervous  branches;  the  former  from  the 
iliac  or  cremasteric  arteries,  the  latter  from  the  genito-crural  nerve. 


72  ORGANS    CONCERNED    IN    PARTURITION. 

According  to  Ranney/  the  principal  function  of  these  ligaments  is  to 
draw  the  uterus  toward  the  symphysis  pubis  during  sexual  intercourse, 
and  thus  to  favor  the  ascent  of  the  semen. 

The  vesico-uterine  ligaments  are  two  folds  of  peritoneum  pass- 
ing in  front  from  the  lower  part  of  the  body  of  the  uterus  to  the  fuudus 
of  the  bladder. 

The  utero-sacral  ligaments  consist  of  folds  of  peritoneum  of  a 
crescentic  form,  with  their  concavities  looking  inward ;  they  start  from 
the  lower  part  of  the  posterior  surface  of  the  uterus,  and  curve  back- 
ward to  be  attached  to  the  third  and  fourth  sacral  vertebrae.  Within 
their  folds  exist  bundles  of  muscular  fibres,  continuous  with  those  of 
the  uterus,  as  well  as  connective  tissue,  vessels,  and  nerves.  The 
experiments  of  Savage,  as  well  as  of  other  anatomists,  show  that  these 
ligaments  have  an  important  influence  in  preventing  downward  dis- 
placement of  the  womb. 

During  pregnancy  all  these  ligaments  become  greatly  stretched  and 
unfolded,  rising  out  of  the  pelvic  cavity  and  accommodating  themselves 
to  the  increased  size  of  the  gravid  uterus ;  and  they  again  contract  to 
their  natural  size,  possibly  through  the  agency  of  the  muscular  fibres 
contained  within  them,  after  delivery  has  taken  place. 

The  Fallopian  tubes,  the  homologues  of  the  vasa  deferentia  in  the 
male,  are  structures  of  great  physiological  interest.  They  serve  the 
double  purpose  of  conveying  the  semen  to  the  ovary,  and  of  carrying 
the  ovule  to  the  uterus.  From  the  latter  function  they  may  be  looked 
on  as  the  excretory  ducts  of  the  ovaries  ;  but,  unlike  other  excretory 
ducts,  they  are  movable,  so  that  they  may  apply  themselves  to  the 
part  of  the  ovaries  from  which  the  ovule  is  to  come ;  and  so  great  is 
their  mobility  that  there  is  reason  to  believe  that  a  Fallopian  tube 
may  even  grasp  the  ovary  of  the  opposite  side.  Each  tube  proceeds 
from  the  upper  angle  of  the  uterus  at  first  transversely  outward,  and 
then  downward,  backward,  and  inward,  so  as  to  reach  the  neighbor- 
hood of  the  ovary.  In  the  first  part  of  its  course  it  is  straight,  after- 
ward it  becomes  flexuous  and  twisted  on  itself.  It  is  contained  in  the 
upper  part  of  the  broad  ligament,  where  it  may  be  felt  as  a  hard  cord. 
It  commences  at  the  uterus  by  a  narrow  opening,  admitting  only  the 
passage  of  a  bristle,  known  as  ostium  uterinum.  As  it  passes  through 
the  muscular  walls  of  the  uterus,  the  tube  takes  a  somewhat  curved 
course,  and  opens  into  the  uterine  cavity  by  a  dilated  aperture.  From 
its  uterine  attachment  the  tube  expands  gradually  until  it  terminates 
in  its  trumpet-shaped  extremity ;  just  before  its  distal  end,  however, 
it  again  contracts  slightly.  The  ovarian  end  of  the  tube  is  surrounded 
by  a  number  of  remarkable  fringe-like  processes.  These  consist  of 
longitudinal  membranous  fimbriae,  surrounding  the  aperture  of  the 
tube,  like  the  tentacles  of  a  polyp,  varying  considerably  in  number 
and  size,  and  having  their  edges  cut  and  subdivided.  On  their  inner 
surface  are  found  both  transverse  and  longitudinal  folds  of  mucous 
membrane,  continuous  with  those  lining  the  tube  itself  (Fig.  33).  One 
of  these  fimbrise  is  always  larger  and  more  developed  than  the  rest, 

1  Amer.  Journ.  Obstet.,  1883,  vol.  xvi.  p.  225. 


THE  FEMALE  GENERATIVE  ORGANS. 


73 


and  is  indirectly  united  to  the  surface  of  the  ovary  by  a  fold  of  peri- 
toneum proceeding  from  its  external  surface.  Its  under  surface  is 
grooved  so  as  to  form  a  channel,  open  below.  The  function  of  this 
fringe-like  structure,  as  has  been  supposed,  is  to  grasp  the  ovary  during 
the  menstrual  uisus ;  and  the  fimbria  which  is  attached  to  the  ovary 
would  seem  to  guide  the  tentacles  to  the  ovary  which  they  are  intended 
to  seize.  It  has  never,  however,  been  demonstrated  that  this  grasping 
of  the  ovary  actually  occurs.  One  or  more  supplementary  series  of 
iimbrite  sometimes  exist,  which  have  an  aperture  of  communication 
with  the  canal  of  the  Fallopian  tube,  beyond  its  ovarian  extremity. 
His  has  recently  shown  that  the  fimbriated  extremity  of  the  tube,  after 
running  over  the  upper  part  of  the  ovary,  turns  down  along  its  free 
border ;  so  that  its  aperture  lies  below  it,  ready  to  receive  the  ovule 
when  expelled  from  the  Graafian  follicle.1 

FIG.  33. 


Fallopim  tubs  laid  opeu.  a,  6.  Uterine  portion  of  tube, 
brane.  e.  Tubo-ovarian  ligaments  and  fringes.  /.  Ovary. 
RICHARD.) 


c,  d.  Plicae  of  mucous  mem- 
g.  Round  ligaments.      (After 


The  tubes  themselves  consist  of  peritoneal,  muscular,  and  mucous 
coats.  The  peritoneum  surrounds  the  tube  for  three-fourths  of  its 
calibre,  and  comes  into  contact  with  the  mucous  lining  at  its  fimbriated 
extremity,  the  only  instance  in  the  body  where  such  a  junction  occurs. 
The  muscular  coat  is  principally  composed  of  circular  fibres,  witli  a 
few  longitudinal  fibres  interspersed.  Its  muscular  character  has  been 
doubted,  but  Farre  had  no  difficulty  in  demonstrating  the  existence  of 
muscular  fibres,  both  in  the  human  female  and  many  of  the  lower 
animals.  According  to  Robin,  the  muscular  tissue  of  the  Fallopian 
tubes  is  entirely  distinct  from  that  of  the  uterus,  from  which  hs 
describes  it  as  being  separated  by  a  distinct  cellular  septum.  The 
mucous  lining  is  thrown  into  a  number  of  remarkable  longitudinal 
folds,  each  of  which  contains  a  dense  and  vascular  fibrous  septum,  with 

'  His  :  Archiv  fiir  Anat.  und  Phys.,  1881. 


74  ORGANS    CONCERNED    IN    PARTURITION. 

small  muscular  fibres,  and  is  covered  with  columnar  and  ciliated  epi- 
thelium. The  apposition  of  these  produces  a  series  of  minute  capillary 
tubes,  along  which  the  ovules  are  propelled,  the  action  of  the  cilia, 
which  is  toward  the  uterus,  apparently  favoring  their  progress. 

The  ovaries  are  the  bodies  in  which  the  ovules  are  formed,  and 
from  which  they  are  expelled,  and  the  changes  going  on  in  them  in 
connection  with  the  process  of  ovulation,  during  the  whole  period 
between  the  establishment  of  puberty  and  the  cessation  of  menstruation, 
have  an  enormous  influence  on  the  female  economy.  Normally,  the 
ovaries  are  two  in  number ;  in  some  exceptional  cases  a  supplementary 
ovary  has  been  discovered ;  or  they  may  be  entirely  absent.  They 
are  placed  in  the  posterior  folds  of  the  broad  ligaments,  usually  below 
the  brim  of  the  pelvis,  behind  the  Fallopian  tubes,  the  left  in  front  of 
the  rectum,  the  right  in  front  of  some  coils  of  the  small  intestine. 
Their  situation  varies,  however,  very  much  under  different  circum- 
stances, so  that  they  can  scarcely  be  said  to  have  a  fixed  and  normal 
position ;  most  probably,  however,  as  has  been  recently  shown  by  His,1 
they  are  normally  placed  close  below  the  brim  of  the  pelvis,  with  their 
long  diameters  almost  vertical,  and  immediately  above  the  aperture  of 
the  distal  extremity  of  the  Fallopian  tubes.  In  pregnancy  they  rise 
into  the  abdominal  cavity  with  the  enlarging  uterus ;  and  in  certain 
conditions  they  are  dislocated  downward  into  Douglas's  space,  where 
they  may  be  felt  through  the  vagina  as  rounded  and  very  tender 
bodies. 

The  folds  of  the  broad  ligament  form  for  them  a  kind  of  loose 
mesentery.  Each  of  them  is  united  to  the  upper  angle  of  the  uterus 
by  a  special  ligament  called  the  utero-ovarian.  This  is  a  rounded 
band  of  organic  muscular  fibres,  about  an  inch  in  length,  continuous 
with  the  superficial  muscular  fibres  of  the  posterior  wall  of  the  uterus, 
and  attached  to  the  inner  extremity  of  the  ovary.  It  is  surrounded 
by  peritoneum,  and  through  it  the  muscular  fibres,  which  form  an 
important  integral  part  in  the  structure  of  the  ovaries,  are  conveyed  to 
them.  The  ovary  is  also  attached  to  the  fimbriated  extremity  of  the 
Fallopian  tube  in  the  manner  already  described. 

The  ovary  is  of  an  irregular  oval  shape  (Fig.  34),  the  upper  border 
being  convex,  the  lower — through  which  the  vessels  and  nerves  enter 
— being  straight.  The  anterior  surface,  like  that  of  the  uterus,  is  less 
convex  than  the  posterior.  The  outer  extremity  is  more  rounded  and 
bulbous  than  the  inner,  which  is  somewhat  pointed  and  eventually  lost 
in  its  proper  ligament.  By  these  peculiarities  it  is  possible  to  dis- 
tinguish the  left  from  the  right  ovary,  after  they  have  been  removed 
from  the  body.  The  ovary  varies  much  in  size  under  different  cir- 
cumstances. On  an  average,  in  adult  life  it  measures  from  one  to  two 
inches  in  length,  three-quarters  of  an  inch  in  width,  and  about  half 
an  inch  in  thickness.  It  increases  greatly  in  size  during  each  men- 
strual period — a  fact  which  has  been  demonstrated  in  certain  cases  of 
ovarian  hernia,  in  which  the  protruded  ovary  has  been  seen  to  swell 
as  menstruation  commenced ;  also  during  pregnancy,  when  it  is  said 

1  Op.  cit. 


THE  FEMALE  GENERATIVE  ORGANS. 


75 


to  be  double  its  usual  size.  After  the  change  of  life  it  atrophies,  and 
becomes  rough  and  wrinked  on  its  surface.  Before  puberty,  the  sur- 
face of  the  ovary  is  smooth  and  polished,  and  of  a  whitish  color. 
After  menstruation  commences,  its  surface,  becomes  scarred  by  the 
rupture  of  the  Graafian  follicles  (Fig.  34,  a  a  a),  each  of  which  leaves  a 
little  linear  or  striated  cicatrix,  of  a  brownish  color;  and  the  older  the 
patient  the  greater  are  the  number  of  these  cicatrices. 


A  A   Ovary  enlarged  under  menstrual  nisus.    B.  Ripe  follicle  projecting  on  its  surface, 
a  a  a  Traces  of  previously  ruptured  follicles. 

The  structure  of  the  ovary  has  been  made  the  subject  of  many 
important  observations.  It  has  an  external  covering  of  epithelium, 
originally  continuous  with  the  peritoneum,  called  by  some  the  germ- 
epithelium,  in  consequence  of  the  ovules  being  formed  from  it  in  early 
foetal  life.  In  the  adult  it  is  separated  from  the  peritoneum  at  the 
base  of  the  organ  by  a  circular  white  line,  and  it  consists  of  columnar 
epithelium,  differing  only  from  the  epithelium  lining  the  Fallopian 
tubes,  with  which  it  is  sometimes  continuous  through  the  attached 
fimbria  uniting  the  tube  and  the  ovary,  in  being  destitute  of  cilia. 
Immediately  beneath  this  covering  is  the  dense  coat  known  as  the 
tunica  albuginea,  on  account  of  its  whitish  color.  It  consists  of  short 
connective-tissue  fibres,  arranged  in  laminae,  among  which  are  inter- 
spersed fusiform  muscular  fibres.  At  the  point  where  the  vessels  and 
nerves  enter  the  ovary  this  membrane  is  raised  into  a  ridge,  which  is 
continuous  with  the  utero-ovarian  ligament,  and  is  called  the  hilum. 
The  tunica  albuginea  is  so  intimately  blended  with  the  stroma  of  the 
ovary  as  to  be  inseparable  on  dissection ;  it  does  not,  therefore,  exist 
as  a  distinct  lamina,  but  is  merely  the  external  part  of  the  proper 
structure  of  the  ovary,  in  which  more  dense  connective  tissue  is  devel- 
oped than  elsewhere. 

On  making  a  longitudinal  section  of  the  ovary  (Fig.  35),  it  will  be 
seen  to  be  composed  of  two  parts,  the  more  internal  of  which  is  of  a 
reddish  color  from  the  number  of  vessels  that  ramify  in  it,  and  is 
called  the  medullary  or  vascular  zone ;  while  the  external,  of  a  whitish 


76 


ORGANS    CONCERNED    IN    PARTURITION. 


FIG.  35. 


tint,  receives  the  name  of  the  cortical  or  parenchymatous  substance. 
The  former  consists  of  loose  connective  tissue  interspersed  with  elastic, 

and  a  considerable  number  of  muscular 
fibres.  According  to  Rouget1  and  His2  the 
muscular  structure  forms  the  greater  part  of 
the  ovarian  stroma.  The  latter  describes  it 
as  consisting  essentially  of  interwoven  mus- 
cular fibres,  which  he  terms  the  "  fusiform 
tissue,"  and  which  he  believes  to  be  con- 
tinuous with  the  muscular  layers  of  the 
ovarian  vessels.  The  former  believes  that 
the  muscular  fasciculi  accompany  the  vessels 
in  the  form  of  sheaths,  as  in  erectile  tissues. 
Both  attribute  to  the  muscular  tissues  an 
important  influence  in  the  expulsion  of  the 
Ovules,  and  in  the  rupture  of  the  Graafian 
follicles.  Waldeyer  and  other  writers,  how- 
ever, do  not  consider  it  to  be  so  extensively  developed  as  Rouget  and  His 
believe.  The  cortical  substance  is  the  more  important,  as  that  in  which 
the  Graafiau  follicles  and  ovules  are  formed.  It  consists  of  interlaced 
fibres  of  connective  tissue,  containing  a  large  number  of  nuclei.  The 


Longitudinal  section  of  adult 
ovary.    (After  FARRE.) 


Section  through  the  cortical  part  of  the  ovary,  e.  Surface  epithelium.  ?  s.  Ovarian  stroma. 
1  1  Large-sized  Graafian  follicles  2  2.  Middle-sized ;  and  3  3.  Small-sized  Croatian  follicles. 
o.  Ovule  within  Graafian  follicle,  v  v.  Bloodvessels  in  the  stroma.  g.  Cells  of  the  membrana  gran- 
ulosa.  (After  TURNER.) 

muscular  fibres  of  the  medullary  substance  do  not  seem  to  penetrate 
into  it  in  the  human  female.  In  it  are  found  the  Graafian  follicles, 
which  exist  in  enormous  numbers  from  the  earliest  periods  of  life,  and 
in  all  stages  of  development  (  Fig.  36). 


1  Journal  de  Physiol.  i.  p.  737. 

*  Schultze's  Arch.  f.  mikroscop.  Anat.,  1865. 


THE  FEMALE  GENERATIVE  ORGANS.          77 

The  Graaflan  Follicles. — According  to  the  researches  of  Pfliiger, 
Waldeyer,  and  other  German  writers,  the  Graafian  follicles  are  formed 
in  early  foetal  life  by  cylindrical  inflections  of  the  epithelial  covering 
of  the  ovary,  which  dip  into  the  substance  of  the  gland.  These  tubular 
filaments  anastomose  with  each  other,  and  in  them  are  formed  the 
ovules,  which  are  originally  the  epithelial  cells  lining  the  tubes.  Por- 
tions become  shut  off  from  the  rest  of  the  filaments,  and  form  the 
Graafian  follicles.  The  ovules,  on  this  view,  are  highly  developed 
epithelial  cells,  originally  derived  from  the  surface  of  the  ovary,  and 
not  developed  in  its  stroma.  These  tubular  filaments  disappear  shortly 
after  birth,  but  they  have  recently  been  detected  by  Slavyansky1  in 
the  ovaries  of  a  woman  thirty  years  of  age.  These  observations  have 
been  modified  by  Dr.  Foulis.2  He  recognizes  the  origin  of  the  ovules 
from  the  germ-epithelium  covering  the  surface  of  the  ovary,  which  is 
itself  derived  from  the  "VVolffian  body.  He  believes  all  the  ovules  to 

FIG.  37. 


Vertical  section  through  the  ovary  of  the  human  foetus.  00.  Germ-epithelium,  withoo.  Develop- 
ing ovules  in  it.  s  s.  Ovarian  stroma  containing  c  c  c.  Fusiform  connective-tissue  corpuscles, 
r  i'.  Capillary  bloodvessels.  In  the  centre  of  the  figure  an  involution  of  the  germ-epithelium  is 
shown ;  and  at  the  left  lower  side  a  primordial  ovule,  with  the  connective-tissue  corpuscles 
ranging  themselves  round  it.  (After  FOULIS.) 

be  formed  from  the  germ-epithelium  corpuscles.  Some  of  these,  which 
are  differentiated  from  the  rest  by  their  greater  size,  rounded  shape, 
and  large  nuclei,  become  imbedded  in  the  stroma  of  the  ovary  by  the 
outgrowth  of  processes  of  vascular  connective  tissue,  fresh  germ- 
epithelial  corpuscles  being  constantly  produced  on  the  surface  of  the 
organ  up  to  the  age  of  two  and  a  half  years,  to  take  the  place  of  those 
already  imbeddedln  its  stroma.  He  believes  the  Graafian  follicles  to 
be  formed  'by  the  growth  of  delicate  processes  of  connective  tissue 
between  and  around  the  ovules,  but  not  from  tubular  inflections  of  the 
epithelium  covering  the  gland,  as  described  by  Waldeyer  (Fig.  37). 
This  view  is  supported  by  the  researches  of  Balfour,3  who  arrives  at 
the  conclusion  that  the  whole  egg-containing  part  of  the  ovary  is  really 

1  Annales  de  Gynec..  Feb.  1871.  ,  _.  .     ...  1B-o 

«  Proceedings  of  the  Royal  Soc.  of  Edinb.,  April,  1875.  and  Journ.  of  Aiiat.  and  Phys vol.  x in.  IS, 
s  F.  M.  Balfour :  "Structure  and  Development  of  Vertebrate  Ovary,"  Quarterly  Journal  of  Micro- 
scopical Science,  vol.  xviii.,  1878. 


78 


ORGANS    CONCERNED    IN    PARTURITION. 


FIG.  3S. 


the  thickened  germinal  epithelium,  broken  up  into  a  kind  of  mesh- 
work  by  growths  of  vascular  stroma.  According  to  this  theory, 
Pfliiger's  tubular  filaments  are  merely  trabeculae  of  germinal  epithe- 
lium, modified  cells  of  which  become  developed  into  ovules. 

The  greater  proportion  of  the  Graafian  follicles  are  only  visible  with 
the  high  powers  of  the  microscope,  but  those  which  are  approaching 
maturity  are  distinctly  to  be  seen  by  the  naked  eye.  The  quantity  of 
these  follicles  is  immense.  Foulis  estimates  that  at  birth  each  human 
ovary  contains  not  less  than  30,000.  No  fresh  follicles  appear  to  be 
formed  after  birth,  and  as  development  goes  on,  some  only  grow,  and, 
by  pressure  on  the  others,  destroy  them.  Of  those  that  grow,  of  course 
only  a  few  ever  reach  maturity ;  they  are  scattered  through  the  sub- 
stance of  the  ovary,  some  developing  in  the  stroma,  others  on  the  sur- 
face of  the  organ,  where  they  eventually  burst,  and  are  discharged  into 
the  Fallopian  tube. 

A  ripe  Graafian  follicle  has -an  external  investing  membrane  (Fig. 
38),  which  is  generally  described  as  consisting  of  two  distinct  layers : 

the  external,  or  tunica  fibrosa, 
highly  vascular,  and  formed  of 
connective  tissue  ;  the  internal, 
or  tunica  propria,  composed  of 
young   connective   tissue,    con- 
taining a  large  number  of  fusi- 
form or  stellate  cells,  and  form- 
ing a  basement  membrane  to  the 
epithelial  layer  which  lies  inter- 
nal to  it.  These  layers,  however, 
appear  to  be  essentially  formed 
of  condensed   ovarian    stroma. 
Within  this  capsule  is  the  epithe- 
lial lining  called  the  membrana 
granulosa,  consisting  of  colum- 
nar    epithelial     cells,     which, 
according  to  Foulis,  are  origi- 
nally formed  from  the  nuclei  of 
the  fibro-nuclear  tissue  of  the 
stroma  of  the  ovary,  but  which,  according  to  AValdeyer  and  Balfour, 
are  formed  from  the  germinal  epithelium  itself.     At  one  part  of  the 
circumference   of   the   ovisac    is   situated   the   ovule,   around   which 
the  epithelial  cells  are  congregated  in  greater  quantity,  constituting 
the  projection  known  as  the  discus  proligerus.     The  remainder  of  the 
cavity  of  the  follicle  is  filled  with  a  small  quantity  of  transparent 
fluid,  the  liquor  folliculi,  traversed  by  three  or  four  minute  bands,  the 
retinacula  of  Barry,  which  are  attached  to  the  opposite  Avails  of  the 
follicular  cavity,   and  apparently   serve  the   purpose   of  suspending 
the  ovule  and  maintaining  it  in  a  proper  position.     In  many  young 
follicles  this  cavity  does  not  at  first  exist,  the  follicle  being  entirely 
filled  by  the  ovule.     According  to  Waldeyer,  the  liquor  folliculi  is 
formed  by  the  disintegration  of  the  epithelial  cells,  the  fluid  thus 
produced  collecting,  and  distending  the  interior  of  the  follicle. 


Diagrammatic  section  of  Graafian  follicle.  1. 
Ovum.  2.  Membrana  granulosa.  3.  External 
membrane  of  Graanan  follicle.  4.  Its  vessels.  5. 
Ovarian  stroma.  6.  Cavity  of  Graafian  follicle. 
7.  External  covering  of  ovary. 


THE  FEMALE  GENERATIVE  ORGANS.          79 

The  Ovule. — The  ovule  is  attached  to  some  part  of  the  internal 
surface  of  the  Graafiau  follicle.  It  is  a  rounded  vesicle  about  T^-7 
of  an  inch  in  diameter,  and  is  surrounded  by  a  layer  of  columnar  cells, 
distinct  from  those  of  the  discus  proligerus,  in  which  it  lies.  It  is 
invested  by  a  transparent  elastic  membrane,  the  zona  pellucida,  or  vitel- 
liue  membrane.  In  most  of  the  lower  animals  the  zona  pcllucida  is 
perforated  by  numerous  very  minute  pores,  only  visible  under  the 
highest  powers  of  the  microscope  ;  in  others  there  is  a  distinct  aperture 
of  a  larger  size,  the  micropyle,  allowing  the  passage  of  the  spermatozoa 
into  the  interior  of  the  ovule.  It  is  possible  that  similar  apertures  may 
exist  in.  the  human  ovule,  but  they  have  not  been  demonstrated. 
Within  the  zona  pellucida  some  embryologists  describe  a  second  fine 
membrane,  the  existence  of  which  has  been  denied  by  Bischoff.  The 
cavity  of  the  ovule  is  filled  with  a  viscid  yellow  fluid,  the  yelk,  con- 
taining numerous  granules.  It  entirely  fills  the  cavity,  to  the  walls  of 
which  it  is  non-adherent.  It  consists  of  primitive  cell  matter,  called 
the  protoplasm  of  the  yelk,  from  which  the  embryo  is  developed,  and 
of  the  granules,  called  the  deutoplasm,  which  furnish  the  nutritive 
material  for  cell  growth.  In  the  centre  of  the  yelk  in  young,  and  at 
some  portion  of  the  periphery  in  mature  ovules,  it  situated  the  germinal 
vesicle,  which  is  a  clear  circular  vesicle,  refracting  light  strongly,  and 
about  ^j-  of  a  line  in  diameter.  It  contains  a  few  granules,  and  a 
iiucleolus,  or  germinal  spot,  which  is  sometimes  double. 


FIG.  39. 


Bulb  of  ovary,    u.  Uterus,    o.  Ovary  and  utero-ovarian  ligament.    T.  Fallopian  tube.    I.  Utero- 
ovarian  vein.    2.  Painpiniform  ovarian  plexus.    3.  Commencemeut  of  spermatic  vein. 

From  within  outward,  therefore,  we  find — 

1.  The  germinal  spot ;  round  this 

2.  The  germinal  vesicle  contained  in 

3.  The  yelk,  which  is  surrounded  by  the 

4.  Zona  pellucida,  with  its  layers  of  columnar  epithelial  cells. 

These  constitute  the  ovule. 

The  ovule  is  contained  in — 

The  Graafian  follicle,  and  lies  in  that  part  of  its  epithelial  lining 
called  the — 


80 


ORGANS    CONCERNED    IN    PARTURITION. 


FIG.  40. 


.Uiscus  proligerus,  the  rest  of  the  follicle  being  occupied  by  the  liquor 
folliculi.  Round  these  we  have  the  epithelial  lining  or  membrana  gran- 
ulosa,  and  the  external  coat,  consisting  of  the  tunica  propria  and  the 
tunica  fibrosa. 

The  vascular  supply  of  the  ovary  is  complex.  The  arteries  enter  at 
the  hilum,  penetrating  the  stroma  in  a  spiral  curve,  and  are  ultimately 
distributed  in  a  rich  capillary  plexus  to  the  follicles.  The  large  veins 
unite  freely  -with  each  other,  and  form  a  vascular  and  erectile  plexus, 
continuous  with  that  surrounding  the  uterus,  called  the  bulb  of  the 
ovary  (Fig.  39).  Lymphatics  and  nerves  exist,  but  their  mode  of 
termination  is  unknown. 

The  Mammary  Glands. — To  complete  the  consideration  of  the 
generative  organs  of  the  female,  we  must  study  the  mammary  glands, 
which  secrete  the  fluid  destined  to  nourish  the  child.  In  the  human 
subject  they  are  two  in  number,  and  instead  of  being  placed  upon  the 

abdomen,  as  in  most  animals,  they  are 
situated  on  either  side  of  the  sternum, 
over  the  pectorales  majora  muscles,  and 
extend  from  the  third  to  the  sixth  ribs. 
This  position  of  the  glands  is  obviously 
intended  to  suit  the  erect  position  of  the 
female  in  suckling.  They  are  convex 
anteriorly,  and  flattened  posteriorly  where 
they  rest  on  the  muscles.  They  vary 
greatly  in  size  in  different  subjects,  chiefly 
in  proportion  to  the  amount  of  adipose 
tissue  they  contain.  In  man,  and  in  girls 
previous  to  puberty,  they  are  rudimentary 
in  structure;  while  in  pregnant  women 
they  increase  greatly  in  size,  the  true  glan- 
dular structures  becoming  much  hypertro- 
phied.  Anomalies  in  shape  and  position 
are  sometimes  observed.  Supplementary 
mammae,  one  or  more  in  number,  situated 
on  the  upper  portion  of  the  niammse  are 
sometimes  met  with,  identical  in  structure 
with  the  normally  situated  glands ;  or, 
more  commonly,  an  extra  nipple  is  observed  by  the  side  of  the  normal 
one.  In  some  races,  especially  the  African,  the  mamma  are  so  enor- 
mously developed  that  the  mother  is  able  to  suckle  her  child  over  her 
shoulder. 

The  skin  covering  the  gland  is  soft  and  supple,  and  during  preg- 
nancy often  becomes  covered  with  fine  white  lines,  while  large  blue 
veins  may  be  observed  coursing  over.  Underneath  it  is  a  quantity  of 
connective  tissue,  containing  a  considerable  amount  of  fat,  which  ex- 
tends between  the  true  glandular  structure.  This  is  composed  of  from 
fifteen  to  twenty  lobes,  each  of  which  is  formed  of  a  number  of  lobules. 
The  lobules  are  produced  by  the  aggregation  of  the  terminal  acini  in 
which  the  milk  is  formed.  The  acini  are  minute  cul-de-sacs  opening 
into  little  ducts,  wJiich  unite  with  each  other  until  they  form  a  large 


1.  Galactophorous  ducts.    2.  Lobuli 
of  the  mammary  gland. 


THE  FEMALE  GENERATIVE  ORGANS.          81 

duct  for  each  lobule ;  the  ducts  of  each  lobule  unite  with  each  other, 
until  they  eud  in  a  still  larger  duct  common  to  each  of  the  fifteen  or 
twenty  lobes  into  which  the  gland  is  divided,  and  eventually  open  on 
the  surface  of  the  nipple.  These  terminal  canals  are  known  as  the 
galadophorous  ducts  (Fig.  40).  They  become  widely  dilated  as  they 
approach  the  nipple,  so  as  to  form  reservoirs  in  which  milk  is  stored 
until  it  is  required,  but  when  they  actually  enter  the  nipple  they  again 
contract.  Sometimes  they  give  off  lateral  branches,  but,  according  to 
Sappey,  they  do  not  anastomose  with  each  other,  as  some  anatomists 
have  described.  These  excretory  ducts  are  composed  of  connective 
tissue,  with  numerous  elastic  fibres  on  their  external  surface.  Sappey 
and  Robin  describe  a  layer  of  muscular  fibres,  chiefly  developed  near 
their  terminal  extremities.  They  are  lined  with  columnar  epithelium, 
continuous  with  that  in  the  acini ;  and  it  is  by  the  distention  of  its 
cells  with  fatty  matter,  and  their  subsequent  bursting,  that  the  milk  is 
formed. 

The  nipple  is  the  conical  projection  at  the  summit  of  the  mamma, 
and  it  varies  in  size  in  different  women.  Not  unfrequently,  from  the 
continuous  pressure  to  which  it  has  been  subjected  by  the  dress,  it  is  so 
depressed  below  the  surface  of  the  skin  as  to  prevent  lactation.  It  is 
generally  larger  in  married  than  in  single  women,  and  increases  in  size 
during  pregnancy.  Its  surface  is  covered  with  numerous  papilla?, 
giving  it  a  rugous  aspect,  and  at  their  bases  the  orifices  of  the  lactifer- 
ous ducts  open.  Here  are  also  the  opening  of  numerous  sebaceous 
follicles,  which  secrete  an  unctuous  material  supposed  to  protect  and 
soften  the  integument  during  lactation.  Beneath  the  skin  are  muscular 
fibres,  mixed  with  connective  and  elastic  tissues,  vessels,  nerves,  and 
lymphatics.  When  the  nipple  is  irritated  it  contracts  and  hardens, 
and  by  some  this  is  attributed  to  its  erectile  properties.  The  vascu- 
larity,  however,  is  not  great,  and  it  contains  no  true  erectile  tissue;  the 
hardening  is,  therefore,  due  to  muscular  contraction.  Surrounding  the 
nipple  is  the  areola,  of  a  pink  color  in  virgins,  becoming  dark  from  the 
development  of  pigment  cells  during  pregnancy,  and  always  remaining 
somewhat  dark  after  childbearing.  On  its  surface  are  a  number  of 
prominent  tubercles,  sixteen  to  twenty  in  number,  which  also  become 
largely  developed  during  gestation.  They  are  supposed  by  some  to 
secrete  milk,  and  to  open  into  the  lactiferous  tubes;  most  probably 
they  are  composed  of  sebaceous  glands  only.  Beneath  the  areola  is  a 
circular  band  of  muscular  fibres,  the  object  of  which  is  to  compress  the 
lactiferous  tubes  which  run  through  it,  and  thus  to  favor  the  expulsion 
of  their  contents.  The  mammae  receive  their  blood  from  the  internal 
mammary  and  intercostal  arteries,  and  they  are  richly  supplied  with 
lymphatic  vessels,  which  open  into  the  axillary  gland.  The  nerves  are 
tlerived  from  the  intercostal  and  thoracic  branches  of  the  brachial 
plexus. 

The  secretion  of  milk  in  women  who  are  nursing  is  accompanied  by 
a  peculiar  sensation,  as  if  milk  were  rushing  into  the  breast,  called  the 
"draught,"  which  is  excited  by  the  efforts  of  the  child  to  suck,  and  by 
various  other  causes.  The  sympathetic  relations  between  the  niarnirue 

6 


82  ORGANS    CONCERNED    IN    PARTURITION. 

and  the  uterus  are  very  well  marked,  as  is  shown  in  the  unimpregnated 
state  by  the  fact  of  the  frequent  occurrence  of  sympathetic  pains  in  the 
breast  in  connection  with  various  uterine  diseases;  and,  after  delivery, 
by  the  well-known  fact  that  suction  produces  reflex  contraction  of  the 
uterus  and  even  severe  after-pains. 


CHAPTEE    III. 

OVULATION  AND  MENSTEUATION. 

Functions  of  the  Ovary. — The  main  function  of  the  ovary  is  to 
supply  the  female  generative  element,  and  to  expel  it,  when  ready  for 
impregnation,  into  the  Fallopian  tube,  along  which  it  passes  into  the 
uterus.  This  process  takes  place  spontaneously  in  all  viviparous  ani- 
mals, and  without  the  assistance  of  the  male.  In  the  lower  animals 
this  periodical  discharge  receives  the  name  of  the  oestrum  or  rut,  at 
which  time  only  the  female  is  capable  of  impregnation  and  admits  the 
approach  of  the  male.  In  the  human  female  the  periodical  discharge 
of  the  ovule,  in  all  probability,  takes  place  in  connection  with  menstru- 
ation, which  may  therefore  be  considered  to  be  the  analogue  of  the  rut 
in  animals.  Between  each  menstrual  period  Graafiau  follicles  undergo 
changes  which  prepare  them  for  rupture  and  the  discharge  of  their 
contained  ovules.  After  rupture  certain  changes  occur  which  have  for 
their  object  the  healing  of  the  rent  in  the  ovarian  tissue  through  which 
the  ovule  has  escaped,  and  the  filling  up  of  the  cavity  in  which  it  was 
contained.  This  results  in  the  formation  of  a  peculiar  body  in  the 
substance  of  the  ovary,  called  the  corpus  luteum,  which  is  essentially 
modified  should  pregnancy  occur,  and  is  of  great  interest  and  impor- 
tance. During  the  whole  of  the  childbearing  epoch  the  periodical 
maturation  and  rupture  of  the  Graafian  follicles  are  going  on.  If  im- 
pregnation does  not  take  place,  the  ovules  are  discharged  and  lost ;  if 
it  does,  ovulation  is  stopped,  as  a  general  rule,  during  gestation  and 
lactation. 

Theory  of  Menstruation. — This,  broadly  speaking,  is  an  outline  of 
the  ovular  theory  of  menstruation,  which  was  first  broached  in  the  year 
1821  by  Dr.  Power,  and  subsequently  elaborated  by  Xegrier,  Bischoff, 
Raciborski,  and  many  other  writers.  Although  the  sequence  of  events 
here  indicated  may  be  taken  to  be  the  rule,  it  must  be  remembered 
that  it  is  one  subject  to  many  exceptions,  for  undoubtedly  ovulation  may 
occur  without  its  outward  manifestation,  menstruation,  as  in  cases  in 
which  impregnation  takes  place  during  lactation,  or  before  menstrua- 
tion has  been  established,  of  which  many  examples  are  recorded. 
These  exceptions  have  led  some  modern  writers  to  deny  the  ovular 


OVULATION    AND    MENSTRUATION.  83 

theory  of  menstruation,  and  their  views  will  require  subsequent  con- 
sideration. 

In  order  to  understand  the  subject  properly,  it  will  be  necessary  to 
study  the  sequence  of  events  in  detail. 

Changes  in  the  Graafian  Follicle. — The  changes  in  the  Graafian 
follicle  which  are  associated  with  the  discharge  of  the  ovules  com- 
prise : 

1.  Maturation.     As  the  period  of  puberty  approaches,  a  certain 
number  of  the  Graafian  follicles,  fifteen  to  twenty  in  number,  increase 
in  size,  and  come  near  the  surface  of  the  ovary.     Amongst  these  one 
becomes  especially  developed,  preparatory  to  rupture,  and  upon  it  for 
the  time  being  all  the  vital  energy  of  the  ovary  seems  to  be  concen- 
trated.    A  similar  change  in  one,  sometimes  in  more  than  one,  follicle 
takes  place  periodically  during  the  whole  of  the  childbearing  epoch, 
in  connection  with  each  menstrual  period,  and  an  examination  of  the 
ovary  will  show  several  follicles  in  different  stages  of  development. 
The  maturing  follicle  becomes  gradually  larger,  until  it  forms  a  pro- 
jection on  the  surface  of  the  ovary,  from  five  to  seven  lines  in  breadth, 
but  sometimes  even  as  large  as  a  nut  (Fig.  34).     This  growth  is  due 
to  the  distention  of  the  follicle  by  the  increase  of  its  contained  fluid, 
which  causes  it  so  to  press  upon  the  ovarian  structures  covering  it  that 
they  become  thinned,  separated  from  each  other,  and  partially  absorbed, 
until  they  eventually  readily  lacerate.    The  follicle  also  becomes  greatly 
congested,  the  capillaries  coursing  over  it  become  increased  in  size  and 
loaded  with  blood,  and  being  seen  through  the  attenuated  ovarian 
tissue,  give  it,  when  mature,  a  bright-red  color.     At  this  time  some 
of  these  distended  capillaries  in  its  inner  coat  lacerate,  and  a  certain 
quantity  of  blood  escapes  into  its  cavity.     This  escape  of  blood  takes 
place  before  rupture,  and  seems  to  have  for  its  principal  object  the 
increase  of  the  tension  of  the  follicle,  of  which  it  has  been  termed  the 
menstruation.     Pouchet  was  of  opinion  that  the  blood  collects  behind 
the  ovule,  and  carries  it  up  to  the  surface  of  the  follicle. 

2.  Escape  of  the  ovule.     By  these  means  the  follicle  is  more  and 
more  distended,  until  at  last  it  ruptures  (Plate  III.,  Fig.  1),  either 
spontaneously,  or,  it  may  be,  under  the  stimulus  of  sexual  excitement. 
Whether  the  laceration  takes  place  during,  before,  or  after  the  men- 
strual discharge  is  not  yet  positively  known  ;  from  the  results  of  post- 
mortem examination  in  a  number  of  women  who  died  shortly  before 
or  after  the  period,  Williams  believes  that  the  ovules  are  expelled 
before  the  monthly  flow  commences.1     In  order  that  the  ovule  may 
escape,  the  laceration  must,  of  course,  involve  not  only  the  coats  of  the 
Graafian  follicles,  but  also  the  superincumbent  structures. 

Laceration  seems  to  be  aided  by  the  growth  of  the  internal  layer  of 
the  follicle,  which  increases  in  thickness  before  rupture,  and  assumes  a 
characteristic  yellow  color  from  the  number  of  oil-globules  it  then 
contains.  It  is  also  greatly  facilitated,  if  it  be  not  actually  produced, 
by  the  turgescence  of  the  ovary  at  each  menstrual  period,  and  by  the 
contraction  of  the  muscular  fibres  in  the  ovarian  stroma.  As  soon  as 
the  rent  in  the  follicular  walls  is  produced,  the  ovule  is  discharged, 

i  Proceedings  of  the  Royal  Society.  1875. 


84 


ORGANS    CONCERNED    IN    PARTURITION. 


surrounded  by  some  of  the  cells  of  the  membrana  granulosa,  arid  is 
received  into  the  fimbriated  extremity  of  the  Fallopian  tube,  which 
has  been  said  to  grasp  the  ovary  over  the  site  of  the  rupture.  This, 
however,  has  never  been  satisfactorily  proved  to  be  the  case.  Henle 
supposed  that  the  ovum  is  washed  into  the  open  extremity  of  the 
Fallopian  tube,  by  means  of  currents  produced  in  the  peritoneal  serum 
by  the  vibration  of  the  cilise  of  the  epithelium  which  covers  both 
surfaces  of  the  fimbriae.  By  the  vibratile  cilia?  of  its  epithelial  lining 
it  is  then  conducted  into  the  canal  of  the  tube,  along  which  it  is  pro- 
pelled, partly  by  ciliary  action,  and  partly  by  muscular  contraction  in 
the  walls  of  the  tube. 

After  the  ovule  has  escaped,  certain  characteristic  changes  occur  in 
the  empty  Graafian  follicle,  which  have  for  their  object  its  cicatrization 
and  obliteration.  There  are  great  differences  in  the  changes  which 
occur  when  impregnation  has  followed  the  escape  of  the  ovule,  and 
they  are  then  so  remarkable  that  they  have  been  considered  certain 
signs  of  pregnancy.  They  are,  however,  differences  of  degree  rather 
than  of  kind.  It  will  be  well,  however,  to  discuss  them  separately. 

As  soon  as  the  ovule  is  discharged,  the  edges  of  the  rent  through 
which  it  has  escaped  become  agglutinated  by  exudation,  and  the  follicle 
shrinks,  as  is  generally  believed,  by  the  inherent  elasticity  of  its  in- 
ternal coat  but  according  to  llobin,  who  denies  the  existence  of  this 
coat,  from  compression  by  the  muscular  fibres  of  the  ovarian  stroma. 
In  proportion  to  the  contraction  that  takes  place,  the  inner  layer  of 
the  follicle,  the  cells  of  which  have  become  greatly  hypertrophied  and 
loaded  with  fat-granules  previous  to  rupture,  is  thrown  into  numerous 
folds  (Plate  III.,  Fig.  2).  Between  these,  young  connective  tissue 

begins  to  form,  and  vascular  offshoots, 
like  papilla?,  arising  from  the  vascular 
network  surrounding  the  follicles,  also 
penetrate  the  interstices.  The  greater 
the  amount  of  contraction  the  deeper 
these  folds  become,  giving  to  a  section  of 
the  follicle  an  appearance  similar  to  that 
of  the  convolutions  of  the  brain  (Fig.  41). 
These  folds  in  the  human  subject  are 
generally  of  a  bright-yellow  color,  but 
in  some  of  the  mammalia  they  are  of  a 
deep  red.  The  tint  was  formerly  ascribed 
by  Raciborski  to  absorption  of  the  color- 
ing matter  of  the  blood-clot  contained  in 
the  follicular  cavity,  a  theory  he  has 
more  recently  abandoned  in  favor  of  the 
view  maintained  by  Coste,  that  it  is  due 
to  the  inherent  color  of  the  cells  of  the 

lining  membrane  of  the  follicle,  which,  though  not  well  marked  in  a 
single  cell,  becomes  very  apparent  en  masse.  The  existence  of  a  con- 
tained blood-clot  is  also  denied  by  the  latter  physiologist,  except  as 
an  unusual  pathological  condition ;  and  he  describes  the  cavity  as 
containing  a  gelatinous  and  plastic  fluid,  which  becomes  absorbed  as 


FIG  41. 


Section  of  ovary,  showing  corpus 
luteum  three  weeks  after  menstrua- 
tion. (After  DALTON.) 


Fig   I. 

ArecantPy    ruptvired    and     bhody   Sraafiart 
j»>ff>cfe.,  just  de-vefopmp'  ivito  a  (xirpws  tutewt 


orpus   Cufeum    ten  days   aftw  menstruation. 


ws  Putamw  o 


ILLUSTRATIONS   OF  THE  CORPUS  LUTEUM.C AFTER  D ALTON) 


OVULATION    AND    MENSTRUATION.  85 

contraction  advances.  The  more  recent  researches  of  Dalton,1  how- 
ever, show  the  existence  of  a  central  blood-clot  in  the  cavity  of  the 
follicle,  and  he  considers  its  occasional  absence  to  be  connected  with 
disturbance  or  cessation  of  the  menstrual  function.  The  folds  into 
which  the  membrane  has  been  thrown  continue  to  increase  in  size, 
from  the  proliferation  of  their  cells,  until  they  unite  and  become 
adherent,  and  eventually  fill  the  follicular  cavity.  By  the  time  that 
another  Graafian  follicle  is  matured  and  ready  for  rupture,  the  dimi- 
nution has  advanced  considerably,  and  the  empty  ovisac  is  reduced  to 
a  very  small  size.  The  cavity  is  now  nearly  obliterated,  the  yellow 
color  of  the  convolutions  is  altered  into  a  whitish  tint,  and  on  section 
the  corpus  luteum  has  the  appearance  of  a  compact  white  stellate 
cicatrix,  which  generally  disappears  in  less  than  forty  days  from  the 
period  of  rupture.  The  tissue  of  the  ovary  at  the  site  of  laceration 
also  shrinks,  and  this,  aided  by  the  contraction  of  the  follicle,  gives 
rise  to  one  of  those  permanent  pits  or  depressions  which  mark  the 
surface  of  the  adult  ovary.  Slavyansky2  has  shown  that  only  a  few 
of  the  immense  number  of  Graafian  follicles  undergo  these  alterations. 
The  greater  proportion  of  them  seem  never  to  discharge  their  ovules, 
but,  after  increasing  in  size,  undergo  retrogressive  changes  exactly 
similar  in  their  nature,  but  to  a  much  less  extent,  to  those  which 
result  in  the  formation  of  a  corpus  luteum.  The  sites  of  these  may 
afterward  be  seen  as  minute  striae  in  the  substance  of  the  ovary. 

Should  pregnancy  occur,"  all  the  changes  above  described  take  place ; 
but,  inasmuch  as  the  ovary  partakes  of  the  stimulus  to  which  all  the 
generative  organs  are  then  subjected,  they  are  much  more  marked  and 
apparent  (Plate  III.,  Fig.  4).  Instead  of  contracting  and  disappear- 
ing in  a  few  weeks,  the  corpus  luteum  continues  to  grow  until  the  third 
or  fourth  month  of  pregnancy ;  the  folds  of  the  inner  layer  of  the 
ovisac  become  large  and  fleshy,  and  permeated  by  numerous  capillaries, 
and  ultimately  become  so  firmly  united  that  the  margins  of  the  con- 
volutions thin  and  disappear,  leaving  only  a  firm  fleshy  yellow  mass, 
averaging  from  1  to  1J  inches  in  thickness,  which  surrounds  a  central 
cavity,  often  containing  a  whitish  fibrillated  structure,  believed  to  be 
the  remains  of  a  central  blood-clot.  This  was  erroneously  supposed 
by  Montgomery  to  be  the  inner  layer  of  the  follicle  itself,  and  he  con- 
ceived the  yellow  substance  to  be  a  new  formation  between  it  and  the 
external  layer;  while  Robert  Lee  thought  it  was  placed  external  to 
both  the  external  and  internal  layers. 

Between  the  third  and  fourth  months  of  pregnancy,  when  the  corpus 
luteum  has  attained  its  maximum  of  development  (Fig.  42),  it  forms  a 
firm  projection  on  the  surface  of  the  ovary,  averaging  about  one  inch 
in  length  and  rather  more  than  half  an  inch  in  breadth.  After  this  it 
commences  to  atrophy  (Fig.  43),  the  fat-cells  become  absorbed,  and  the 
capillaries  disappear.  Cicatrization  is  not  complete  until  from  one  to 
two  months  after  delivery. 

On  account  of  the  marked  appearance  of  the  corpus  luteum,  it  was 
formerly  considered  to  be  an  infallible  sign  of  pregnancy ;  and  it  was 


1  "  Report  on  the  Corpus  Luteum," 
-  Archiv  de  Pbys.,  March,  1S74. 


American  Gynec.  Trans.,  1877,  vol.  ii.  p.  111. 


86  ORGANS    CONCERNED    IN    PARTURITION. 

distinguished  from  the  corpus  luteum  of  the  non-pregnant  state  by 
being  called  a  "  true  "  as  opposed  to  a  "  false  "  corpus  luteum.  From 
what  has  been  said  it  will  be  obvious  that  this  designation  is  essentially 
wrong,  as  the  difference  is  one  of  degree  only.  Dalton1  applies  the 
term  "  false  corpus  luteum  "  to  a  degenerated  condition  sometimes  met 
with  in  an  unruptured  Graafian  follicle  consisting  in  reabsorption  of 
its  contents  and  thickening  of  its  walls  (Plate  III.,  Fig.  3).  It  differs 
from  the  "  true "  corpus  luteum  in  being  deeply  seated  in  the  substance 
of  the  ovary,  in  having  no  central  clot,  and  in  being  unconnected  with 
a  cicatrix  on  the  surface  of  the  ovary.  Xor  do  obstetricians  attach  by 
any  means  the  same  importance  as  they  did  formerly  to  the  presence  of 
the  corpus  luteum  as  indicating  impregnation ;  for  even  when  \vell 
marked,  other  and  more  reliable  signs  of  recent  delivery,  such  as 
enlargement  of  the  uterus,  are  sure  to  be  present,  especially  at  the  time 
when  the  corpus  luteum  has  reached  its  maximum  of  development ; 
while  after  delivery  at  term  it  has  no  longer  a  sufficiently  characteristic 
appearance  to  be  depended  on. 

FIG.  42.  FIG.  43. 


Corpus  luteum  of  the  fourth  month  of  pregnancy  Corpus  luteum  of  pregnancy  at 

(After  DALTOX.)  term.    (After  DALTON.) 

Menstruation. — By  the  term  menstruation  (catamenia,  periods,  etc.) 
is  meant  the  periodical  discharge  of  blood  from  the  uterus  which 
occurs,  in  the  healthy  woman,  every  lunar  month,  except  during  preg- 
nancy and  lactation,  when  it  is,  as  a  rule,  suspended. 

The  first  appearance  of  menstruation  coincides  with  the  establish- 
ment of  puberty,  and  the  physical  changes  that  accompany  it  indicate 
that  the  female  is  capable  of  conception  and  childbearing,  although 
exceptional  cases  are  recorded  in  which  pregnancy  occurred  before 
menstruation  had  begun.  In  the  temperate  climates  it  generally  com- 
mences between  the  fourteenth  and  sixteenth  years,  the  largest  number 
of  cases  being  met  with  in  the  fifteenth  year.  This  rule  is  subject  to 
many  exceptions,  it  being  by  no  means  very  rare  for  menstruation  to 
become  established  as  early  as  the  tenth  or  eleventh  year,  or  to  be 

i  Op.  cit.,  p.  64. 


OVULATION    AND    MENSTRUATION.  87 

delayed  until  the  eighteenth  or  twentieth.  Beyond  these  physiological 
limits  a  few  cases  are  from  time  to  time  met  with  in  which  it  has  begun 
in  early  infancy,  or  not  until  a  comparatively  late  period  of  life. 

Influence  of  Climate,  Race,  etc. — Various  accidental  circumstances 
have  much  to  do  with  its  establishment.  As  a  rule  it  occurs  somewhat 
earlier  in  tropical,  and  later  in  very  cold  than  in  temperate  climates. 
The  influence  of  climate  has  been  unduly  exaggerated.  It  used  to  be 
generally  stated  that  in  the  Arctic  regions  women  did  not  menstruate 
until  they  were  of  mature  age,  and  that  in  the  tropics  girls  of  ten  or 
twelve  years  of  age  did  so  habitually.  The  researches  of  Robertson, 
of  Manchester,1  first  showed  that  the  generally  received  opinions  were 
erroneous ;  and  the  collection  of  a  large  number  of  statistics  has  cor- 
roborated his  opinion.  There  can  be  no  doubt,  however,  that  a  larger 
proportion  of  girls  menstruate  early  in  warm  climates.  Joulin  found 
that  in  tropical  climates,  out  of  1635  cases,  the  largest  proportion  began 
to  menstruate  between  the  twelfth  and  thirteenth  years ;  so  that  there 
is  an  average  difference  of  more  than  two  years  between  the  period  of 
its  establishment  in  the  tropics  and  in  temperate  countries.  Harris2 
states  that  among  the  Hindoos  1  to  2  per  cent,  menstruate  as  early  as 
nine  years  of  age  ;  3  to  4  per  cent,  at  ten  ;  8  per  cent,  at  eleven ;  and 
25  per  cent,  at  twelve ;  while  in  London  or  Paris  probably  not  more 
than  one  girl  in  1000  or  1200  does  so  at  nine  years.  The  converse 
holds  true  with  regard  to  cold  climates,  although  we  are  not  in  pos- 
session of  a  sufficient  number  of  accurate  statistics  to  draw  very  reliable 
conclusions  on  this  point ;  but  out  of  4715  cases,  including  returns  from 
Denmark,  Norway  and  Sweden,  Russia,  and  Labrador,  it  was  found 
that  menstruation  was  established  on  an  average  a  year  later  than  in 
more  temperate  countries.  It  is  probable  that  the  mere  influence  of 
temperature  has  much  to  do  in  producing  these  differences,  but  there  are 
other  factors,  the  action  of  which  must  not  be  overlooked.  Raciborski 
attributes  considerable  importance  to  the  effect  of  race ;  and  he  has 
quoted  Dr.  Webb,  of  Calcutta,  to  the  effect  that  English  girls  in  India, 
although  subjected  to  the  same  climatic  influence  as  the  Indian  races, 
do  not,  as  a  rule,  menstruate  earlier  than  in  England ;  while,  in  Austria, 
girls  of  the  Magyar  race  menstruate  considerably  later  than  those  of 
German  parentage.3  The  surroundings  of  girls,  and  their  manner  of 
education  and  living,  have  probably  also  a  marked  influence  in  pro- 
moting or  retarding  its  establishment.  Thus,  it  will  commence  earlier 
in  the  children  of  the  rich,  who  are  likely  to  have  a  highly  developed 
nervous  organization,  and  are  habituated  to  luxurious  living,  and  a 
premature  stimulation  of  the  mental  faculties  by  novel-reading,  society, 
and  the  like;  while'amongst  the  hard-worked  poor, or  in  girls  brought 
up  in  the  country,  it  is  more  likely  to  begin  later.  Premature  sexual 
excitement  is  said  also  to  favor  its  early  appearance,  and  the  influence 
of  this  among  the  factory  girls  of  Manchester,  who  are  exposed  in  the 
course  of  their  work  to  the  temptations  arising  from  the  promiscuous 
mixing  of  the  sexes,  has  been  pointed  out  by  Dr.  Clay.4 

1  Edin.  Med.  and  Surg.  Tourn.,  1832. 

2  Amer.  Journ.  of  Obstet.,  1870-71.  vol.  iii.  p.  611.    R.  P.  Harris  "On  Early  Puberty." 
s  Op  cit    p  227  4  Brit.  Record  of  Obstet.  Med.,  vol.  i. 


88  ORGANS    CONCERNED    IN    PARTURITION. 

[Precocious  Physical  Womanhood. — "NVe  emphasize  the  term 
"  physical/'  because  in  a  mental  and  moral  sense  the  subjects  are  for- 
tunately, with  rare  exceptions,  only  children  in  years  and  tastes.  Pre- 
cociously developed  girls  are,  as  a  rule,  of  very  unusual  size  for  their 
years,  and  usually  enjoy  good  health,  while  precocity  in  male  children 
is  apt  to  be  associated  with  semi-idiocy  and  epilepsy.  Where  men- 
struation begins  in  the  first  year,  the  girl  may  at  three  or  four  years 
of  age  present  the  evidences  of  puberty  in  the  appearance  of  pubic 
and  axillary  hair,  rounded  mammae,  and  a  broad  pelvis,  associated 
with  well-rounded  arms  and  legs  and  a  strength  and  height  much 
beyond  her  years.  In  three  children  born  in  this  State,  these  charac- 
teristics were  marked,  respectively,  at  four  and  a  half  years,  five,  and 
six.  The  five-year-old  girl  was  a  beautifully  formed  miniature  woman, 
and  the  one  of  six  was  large,  fat,  and  had  the  developed  features  of 
twice  her  age ;  still,  she  was  only  a  child  in  tastes,  and  as  such  devoted 
to  her  dolls  and  toys.  The  sexual  passion  is  very  rarely  a  marked 
characteristic  in  such  subjects,  as  it  is  in  the  other  sex,  and  hence  the 
ability  to  procreate  has  rarely  been  tested;  but  occasionally  in  the 
lower  classes  pregnancy  has  occurred  at  an  early  age. 

The  youngest  English  mother  on  record  was  nine  years  seven  months 
and  nine  days  old  when  Mr.  Henry  Dodd,  of  Billington,  York,  who 
was  present  at  her  birth,  delivered  her  of  a  seven-pound  healthy  child, 
after  a  labor  of  six  hours,  on  March  17,  1881.  She  commenced  to 
menstruate  at  twelve  months,  and  became  pregnant  about  six  weeks 
before  she  was  nine  years  old.1 

The  youngest  American  mother  became  such  at  ten  years  and  thir- 
teen days,  giving  birth  to  a  child  of  seven  and  three-quarters  pounds. 
She  also  menstruated  at  one  year,  and  at  the  time  of  her  la!x»r  was 
four  feet  seven  inches  in  height  and  weighed  one  hundred  pounds. 
The  case  was  reported  by  Dr.  llowlett,  of  Kentucky.2  A  still  younger 
mother  was  reported  by  Schmitt  more  than  a  century  ago.  The  child 
began  to  menstruate  at  two  years,  and  when  eight  years  and  ten 
months  old  bore  a  dead  fcetus  which  was  thought  by  its  development 
to  have  reached  its  full  term.  The  mother  had  the  mammae  and  pubes 
of  a  girl  of  seventeen.3 — ED.] 

Changes  Occurring-  at  Puberty. — The  first  appearance  of  men- 
struation is  accompanied  by  certain  well-marked  changes  in  the  female 
system,  on  the  occurrence  of  which  we  say  that  the  girl  has  arrived  at 
the  period  of  puberty.  The  pubes  become  covered  with  hair,  the 
breasts  enlarge,  the  pelvis  assumes  its  fully  developed  form,  and  the 
general  contour  of  the  body  fills  out.  The  mental  qualities  also  alter ; 
the  girl  becomes  more  shy  and  retiring,  and  her  whole  bearing  indi- 
cates the  change  that  has  taken  place.  The  menstrual  discharge  is  not 
established  regularly  at  once.  Eor  one  or  two  months  there  may  be 
only  premonitory  symptoms — a  vague  sense  of  discomfort,  pains  in 
the  breasts,  and  a  feeling  of  weight  and  heat  in  the  back  and  loins. 
There  then  may  be  a  discharge  of  mucus  tinged  with  blood,  or  of 


Barnes's  Obstetric  Medicine  and  Surgery.] 
"i.  p.  447.] 


P  Transylvania  Med.  Journ.,  vol.  vii.  . 

[3  Sue's  Essais  bistoriques,  Paris,  1779,  vol.  ii.  p.  344.] 


OVULATION    AND    MENSTRUATION.  89 

pure  blood,  and  this  may  not  again  show  itself  for  several  months. 
Such  irregularities  are  of  little  consequence  on  the  first  establishment 
of  the  function,  and  need  give  rise  to  110  apprehension. 

Duration. — As  a  rule,  the  discharge  recurs  every  twenty-eight  days, 
and  with  some  women  with  such  regularity  that  they  can  foretell  its 
appearance  almost  to  the  hour.  The  rule  is,  however,  subject  to  very 
great  variations.  It  is  by  no  means  uncommon,  and  strictly  within 
the  limits  of  health,  for  it  to  appear  every  twentieth  day,  or  even  with 
less  interval ;  while  in  other  cases  as  much  as  six  weeks  may  habitu- 
ally intervene  between  two  periods.  The  period  of  recurrence  may 
also  vary  in  the  same  subject.  I  am  acquainted  with  patients  who 
sometimes  only  have  twenty-eight  days,  at  others  as  .many  as  forty- 
eight  days,  between  their  periods,  without  their  health  in  any  way 
suffering.  Joulin  mentions  the  case  of  a  lady  who  only  menstruated 
two  or  three  times  in  the  year,  and  whose  sister  had  the  same  pecu- 
liarity. 

The  duration  of  the  period  varies  in  different  women,  and  in  the 
same  woman  at  different  times.  In  this  country  its  average  is  four  or 
five  days,  while  in  France,  Dubois  and  Brierre  de  Boismont  fix  eight 
days  as  the  most  usual  length.  Some  wromen  are  only  unwell  for  a 
few  hours,  while  in  others  the  period  may  last  many  days  beyond  the 
average  without  being  considered  abnormal. 

The  quantity  of  blood  lost  varies  in  different  women.  Hippocrates 
puts  it  at  §xviij,  which,  however,  is  much  too  high  an  estimate. 
Arthur  Farre  thinks  that  from  §ij  to  §iij  is  the  full  amount  of  a 
healthy  period,  and  that  the  quantity  cannot  habitually  exceed  this 
without  producing  serious  constitutional  effects.  Rich  diet,  luxurious 
living,  and  anything  that  unhealthily  stimulates  the  body  and  mind, 
Avill  have  an  injurious  effect  in  increasing  the  flow,  which  is,  therefore, 
];-s  in  hard-worked  countrywomen  than  in  the  better  classes  and 
residents  in  towns. 

It  is  more  abundant  in  warm  climates,  and  our  countrywomen  in 
India  habitually  menstruate  over-profusely,  becoming  less  abundantly 
unwell  when  they  return  to  England.  The  same  observation  has  been 
made  with  regard  to  American  women  residing  in  the  Gulf  States,  who 
improve  materially  by  removing  to  the  Lake  States.  Some  women 
appear  to  menstruate  more  in  summer  than  in  winter.  I  am  acquainted 
with  a  lady  who  spends  the  winter  in  St.  Petersburg,  where  her  periods 
last  eight  or  ten  days,  and  the  summer  in  England,  where  they  never 
exceed  four  or  five.  The  difference  is  probably  due  to  the  effect  of  the 
overheated  rooms  in  which  she  lives  in  Russia. 

The  daily  loss  is  not  the  same  during  the  continuance  of  the  period. 
It  generally  is  at  first  slight,  and  gradually  increases  so  as  to  be  most 
profuse  on  the  second  or  third  day,  and  as  gradually  diminishes. 
Toward  the  last  days  it  sometimes  disappears  for  a  few  hours,  and 
then  comes  on  again,  and  is  apt  to  recur  under  any  excitement  or 
emotion. 

As  the  menstrual  fluid  escapes  from  the  uterus  it  consists  of  pure 
blood,  and  if  collected  through  the  speculum,  it  coagulates.  The 
ordinary  menstrual  fluid  does  not  coagulate  unless  it  is  excessive  in 


90  ORGANS    CONCERNED    IN    PARTURITION. 

amount.  Various  explanations  of  this  fact  have  been  given.  It  was 
formerly  supposed  either  to  contain  no  fibrin,  or  an  unusually  small 
amount.  Retzius  attributes  its  non-coagulation  to  the  presence  of  free 
lactic  and  phosphoric  acids.  The  true  explanation  was  first  given  by 
Mandl,  who  proved  that  even  small  quantities  of  pus  or  mucus  in 
blood  Avere  sufficient  to  keep  the  fibrin  in  solution ;  and  mucus  is 
always  present  to  greater  or  less  amount  in  the  secretions  of  the  cervix 
and  vagina,  which  mix  with  the  menstrual  blood  in  its  passage  through 
the  genital  tract.  If  the  amount  of  blood  be  excessive,  however,  the 
mucus  present  is  insufficient  in  quantity  to  produce  this  effect,  and 
coagula  are  then  formed. 

On  microscopic  examination  the  menstrual  fluid  exhibits  blood 
corpuscles,  mucous  corpuscles,  and  a  considerable  amount  of  epithelial 
scales,  the  last  being  the  debris  of  the  epithelium  lining  the  uterine 
cavity.  According  to  Virchow,  the  form  of  the  epithelium  often 
proves  that  it  comes  from  the  interior  of  the  utricular  glands.  The 
color  of  the  blood  is  at  first  dark,  and  as  the  period  progresses  it  gen- 
erally becomes  lighter  in  tint.  In  women  who  are  in  bad  health  it  is 
often  very  pale.  These  differences  doubtless  depend  upon  the  amount 
of  mucus  mingled  with  it.  The  menstrual  blood  has  always  a  char- 
acteristic faint  and  heavy  odor,  which  is  analogous  to  that  which  is 
so  distinct  in  the  lower  animals  during  the  rut.  Raciborski  mentions 
a  lady  who  was  so  sensitive  to  this  odor  that  she  could  always  tell  to 
a  certainty  when  any  woman  was  menstruating.  It  is  attributed  either 
to  decomposing  mucus  mixed  with  the  blood,  which,  when  partially 
absorbed,  may  cause  the  peculiar  odor  of  the  breath  often  perceptible 
in  menstruating  women ;  or  to  the  mixture  with  the  fluid  of  the 
sebaceous  secretion  from  the  glands  of  the  vulva.  It  probably  gave 
rise  to  the  old  and  prevalent  prejudices  as  to  the  deleterious  properties 
of  menstrual  blood,  which,  it  is  needless  to  say,  are  altogether  without 
foundation. 

It  is  now  universally  admitted  that  the  source  of  the  menstrual 
blood  is  the  mucous  membrane  lining  the  interior  of  the  uterus,  for 
the  blood  may  be  seen  oozing  through  the  os  uteri  by  means  of  the 
speculum,  and  in  cases  of  prolapsus  uteri ;  while  in  cases  of  inverted 
uterus  it  may  be  actually  observed  escaping  from  the  exposed  mucous 
membrane,  and  collecting  in  minute  drops  upon  its  surface.  During 
the  menstrual  nisus  the  whole  mucous  lining  becomes  congested  to 
such  an  extent  that,  in  examining  the  bodies  of  women  who  have  died 
during  menstruation,  it  is  found  to  be  thicker,  larger,  and  thrown  into 
folds,  so  as  to  completely  fill  the  uterine  cavity.  The  capillary  cir- 
culation at  this  time  becomes  very  marked,  and  the  mucous  membrane 
assumes  a  deep-red  hue,  the  network  of  capillaries  surrounding  the 
orifices  of  the  utricular  glands  being  especially  distinct.  These  facts 
have  an  unquestionable  connection  with  the  production  of  the  dis- 
charge, but  there  is  much  difference  of  opinion  as  to  the  precise  mode 
in  which  the  blood  escapes  from  the  vessels.  Coste  believed  that  the 
blood  transudes  through  the  coats  of  the  capillaries  without  any 
laceration  of  their  structure.  Farre  inclines  to  the  hypothesis  that  the 
uterine  capillaries  terminate  by  open  mouths,  the  escape  of  blood 


OVULATION    AND    MENSTRUATION.  91 

through  these,  between  the  menstrual  periods,  being  prevented  by 
muscular  contraction  of  the  uterine  walls.  Pouchet  believed  that 
during  each  menstrual  epoch  the  entire  mucous  membrane  is  broken 
down  and  cast  off  in  the  form  of  minute  shreds,  a  fresh  mucous  mem- 
brane being  developed  in  the  interval  between  two  periods.  During 
this  process  the  capillary  network  would  be  laid  bare  and  ruptured, 
and  the  escape  of  blood  readily  accounted  for.  Tyler  Smith,  who 
adopted  this  theory,  states  that  he  has  frequently  seen  the  uterine 
mucous  membrane,  in  women  who  have  died  during  menstruation,  in 
a  state  of  dissolution,  with  the  broken  loops  of  the  capillaries  exposed. 
The  phenomena  attending  the  so-called  membranous  dysmenorrhoea, 
in  which  the  mucous  membrane  is  thrown  off  in  shreds,  or  as  a  cast 
of  the  uterine  cavity — the  nature  of  which  was  first  pointed  out  by 
Simpson  and  Oldham — have  been  supposed  to  corroborate  this  theory. 
This  view  is,  in  the  main,  corroborated  by  the  recent  researches  of 
Engelmann,1  Williams,2  and  others.  Williams  describes  the  mucous 
lining  of  the  uterus  as  undergoing  a  fatty  degeneration  before  each 
period,  which  commences  near  the  inner  os,  and  extends  over  the  whole 
mucous  membrane,  and  down  to  the  muscular  wall.  This  seems  to 
bring  on  a  certain  amount  of  muscular  contraction,  which  drives  the 
blood  into  the  capillaries  of  the  mucosa,  and  these,  having  become 
degenerated,  readily  rupture,  and  permit  the  escape  of  the  blood.  The 
mucous  membrane  now  rapidly  disintegrates,  and  is  cast  off  in  shreds 
with  the  menstrual  discharge,  in  which  masses  of  epithelial  cells  may 
always  be  detected.  Engelmann,  however,  holds  that  the  fatty  degen- 
eration is  limited  to  the  superficial  layers,  and  that  a  portion  only  of 
the  epithelial  investment  is  thrown  off.  As  soon  as  the  period  is  over, 
the  formation  of  a  new  mucous  membrane  is  begun,  which  arises  either 
from  proliferation  of  the  elements  of  the  muscular  coat  itself,  or  from 
the  proliferation  of  the  epithelial  cells  lining  the  bases  of  the  uterine 
glands  Avhich  remain  imbedded  in  the  muscular  tissue  after  the  mucous 
membrane  has  been  thrown  off,  and  at  the  end  of  a  week  the  whole 
uterine  cavity  is  lined  by  a  thin  mucous  membrane.  This  grows  until 
the  advent  of  another  period,  when  the  same  degenerative  changes 
occur  unless  impregnation  has  taken  place,  in  which  case  it  becomes 
further  developed  into  the  decidua.  Lowenthal3  believes  that  the 
menstrual  decidua  is  produced  by  the  imbedding  of  an  ovum  in  the 
lining  membrane  of  the  uterus,  which,  if  impregnation  occurs,  is 
developed  into  the  decidua  of  pregnancy.  If  conception  does  not 
take  place,  the  ovum  dies,  and  this  is  followed  by  the  degeneration 
and  expulsion  of  the  menstrual  decidua,  accompanied  by  a  flow  of 
blood,  which  is  the  menstrual  discharge. 

Theory  of  Menstruation. — That  there  is  an  intimate  connection 
between  ovulation  and  menstruation  is  admitted  by  most  physiologists, 
and  it  is  held  by  many  that  the  determining  cause  of  the  discharge  is 
the  periodic  maturation  of  the  Graafian  follicles.  There  is  abundant 

1  American  Journal  of  Obstetrics,  1875-76,  vol.  viii.  p.  30. 

*  "On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,"  Obstet.  Journ.,  1875-76,  vol.  Hi. 

'3  Arch.  f.  Gyn.,  Bd.  xxiv.,  Heft  2,  8. 169 :  "  Eine  neue  Deutung  des  Menstruations-Prozess." 


92  ORGANS    CONCERNED    IN    PARTURITION. 

evidence  of  this  connection,  for  we  know  that  when,  at  the  change  of 
life,  the  Graafian  follicles  cease  to  develop,  menstruation  is  arrested  ; 
and  when  the  ovaries  are  removed  by  operation,  of  which  there  are  now 
numerous  cases  on  record,  or  when  they  are  cougenitally  absent,  men- 
struation does  not  generally  take  place.  A  few  cases,  however,  have 
been  observed  in  which  menstruation  continued  after  double  ovari- 
otomy, or  the  removal  of  the  ovaries  by  Battey's  operation,  and  these 
have  been  used  as  an  argument  by  those  physiologists  who  doubt  the 
ovular  theory  of  menstruation.  Slavyansky  has  particularly  insisted 
on  such  cases,  which,  however,  are  probably  susceptible  of  explanation. 
It  may  be  that  the  habit  of  menstruation  may  continue  for  a  time  even 
after  the  removal  of  the  ovaries ;  and  it  has  not  been  shown  that  men- 
struation has  continued  permanently  after  double  ovariotomy,  although 
it  certainly  has  occasionally,  although  quite  exceptionally,  done  so  for 
a  time.  It  is  possible,  also,  that  in  such  cases  a  small  portion  of  ovarian 
tissue  may  have  been  left  unremoved,  sufficient  to  carry  on  ovulation. 
Roberts,  a  traveller  quoted  by  Depaul  and  Gue"niot  in  their  article  on 
Menstruation  in  the  Dictionnaire  des  Sciences  Medicales,  relates  that  in 
certain  parts  of  Central  Asia  it  is  the  custom  to  remove  both  ovaries  in 
young  girls  who  act  as  guards  to  the  harems.  These  women,  known 
as  "hedjeras,"  subsequently  assume  much  of  the  virile  type,  and  never 
menstruate.  The  same  close  connection  between  ovulation  and  the  rut 
of  animals  is  observed,  and  supports  the  conclusion  that  the  rut  and 
menstruation  are  analogous.  The  chief  difference  between  ovulatiou 
in  man  and  the  lower  animals  is  that  in  the  latter  the  process  is  not 
generally  accompanied  by  a  sanguineous  flow.  To  this  there  are  excep- 
tions, for  in  monkeys  there  is  certainly  a  discharge  analogous  to  men- 
struation occurring  at  intervals. 

Another  point  of  distinction  is  that  in  animals  connection  never 
takes  place  except  during  the  rut,  and  that  it  is  then  only  that  the 
female  is  capable  of  conception  ;  while  in  the  human  race  conception 
only  occurs  in  the  interval  between  the  periods.  This  is  another  argu- 
ment brought  against  the  ovular  theory,  because,  it  is  said,  if  menstrua- 
tion depend  on  the  rupture  of  a  Graafian  follicle  and  the  emission  of 
an  ovule,  then  impregnation  should  only  take  place  during  or  imme- 
diately after  menstruation.  Coste  explains  this  by  supposing  that  it  is 
the  maturation  and  not  the  rupture  of  the  follicle  which  determines  the 
occurrence  of  menstruation  ;  and  that  the  follicle  may  remain  imrnp- 
tured  for  a  considerable  time  after  it  is  mature,  the  escape  of  the  ovule 
being  subsequently  determined  by  some  accidental  cause  such  as  sexual 
excitement.  However  this  may  be,  there  is  good  reason  to  believe  that 
the  susceptibility  to  conception  is  greater  during  the  menstrual  epochs. 
Raciborski  believes  that  in  the  large  proportion  of  cases  impregnation 
occurs  in  the  first  half  of  the  menstrual  interval,  or  in  the  few  days 
immediately  preceding  the  appearance  of  the  discharge.  There  are, 
however,  very  numerous  exceptions,  for  in  Jewesses,  who  almost  inva- 
riably live  apart  from  their  husbands  for  eight  days  after  the  cessation 
of  menstruation,  impregnation  must  constantly  occur  at  some  other 
period  of  the  interval,  and  it  is  certain  that  they  are  not  less  prolific 
than  other  people.  This  rule  with  them  is  very  strictly  adhered  to,  as 


OVULATION    AND    MENSTRUATION.  93 

will  be  seen  by  the  accompanying  interesting  letter  from  a  medical 
friend  who  is  a  well-known  member  of  that  community,  and  which  I 
have  permission  to  publish.1  This  fact  is  of  itself  sufficient  to  disprove 
the  theory  advanced  by  Dr.  Avrard,2  that  impregnation  is  impossible 
in  the  latter  half  of  the  menstrual  interval.  This,  and  the  other  reasons 
referred  to,  undoubtedly  throw  some  doubt  on  the  ovular  theory,  but 
they  do  not  seem  to  be  sufficient  to  justify  the  conclusion  that  men- 
struation is  a  physiological  process  altogether  independent  of  the 
development  and  maturation  of  the  Graafian  follicles.  All  that  they 
can  be  fairly  held  to  prove  is  that  the  escape  of  the  ovules  may  occur 
independently  of  menstruation,  but  the  weight  of  evidence  remains 
strongly  in  favor  of  the  theory  which  is  generally  received. 

It  should  be  stated  that  several  recent  writers,  Lawson  Tait  amongst 
the  number,  attribute  considerable  influence  in  menstruation  to  the 
Fallopian  tubes.  Robinson,  of  Chicago,  in  an  interesting  paper,3  con- 
tends that  menstruation  is  governed  by  nervous  ganglia  situated  in  the 
walls  of  the  Fallopian  tubes  and  uterus,  which  he  calls  "automatic 
menstrual  ganglia."  These  he  considers  to  be  analogous  to  the  nerve 
ganglia  found  in  the  heart,  intestines,  and  other  hollow  viscera,  and  to 
have  the  function  of  producing  rhythmical  peristalsis  in  the  tubes, 
which  favors  the  passage  of  the  ovum  along  their  canal.  He  believes 
that  ovulation  is  entirely  unconnected  with  menstruation,  and  goes  on 
independently  of  it,  the  greater  part  of  the  ovules  being  lost  in  the 
peritoneal  cavity ;  and  that  it  is  only  when  the  periodic  and  rhythmical 
action  of  the  tubes  begins  that  menstruation  is  established.  These 
views  cannot  be  taken  as  proved,  but  they  certainly  suggest  an  explana- 
tion of  some  of  the  phenomena  of  menstruation  otherwise  difficult  to 
understand,  such  as  its  occasional  continuance  after  the  removal  of  the 
ovaries,  and  are  well  worthy  of  further  investigation. 

The  cause  of  the  monthly  periodicity  is  quite  unknown,  and  will 
probably  always  remain  so.  Goodman4  has  suggested  what  he  calls  the 
"  cyclical  theory  of  menstruation,"  which  refers  the  phenomena  to  a 

i  10  BERNARD  STREET,  RUSSELL  SQUARE,  July  21, 1873. 

MY  DEAR  SIR  :  1.  To  the  best  of  my  knowledge  and  belief,  the  law  which  prohibits  sexual 
intercourse  among  Jews  for  seven  clear  days  after  the  cessation  of  menstruation,  is  almost 
universally  observed,  the  exceptions  not  being  sufficient  to  vitiate  statistics.  The  law  has  perhaps 
fewer  exceptions  on  the  Continent— especially  Russia  and  Poland,  where  the  Jewish  population  is 
very  great — than  in  England.  Even  here,  however,  women  who  observe  no  other  ceremonial  Jaw 
observe  this,  and  cling  to  it  after  everything  else  is  thrown  overboard.  There  are  doubtless  many 
exceptions,  especially  among  the  better  classes  in  England,  who  keep  only  three  days  after  the 
cessation  of  the  menses. 

2.  The  law  is— as  you  state— that  should  the  discharge  last  only  an  hour  or  so,  or  should  there  be 
only  one  gush  or  one  spot  on  the  linen,  the  five  days  during  which  the  period  might  continue  are 
observed  ;  to  which  must  be  superadded  the  seven  clear  days— twelve  days  per  mensem  in  which 
connection  is  disallowed.    Should  any  discharge  be  seen  in  the  inter-menstrual  period,  seven  days 
would  have  to  be  kept,  but  not  the  five,  for  such  Irregular  discharge. 

3.  The  "bath  of  purification,"  which  must  contain  at  Imsl  eighty  gallons,  is  used  on  the  last 
night  of  the  seven  clear  days.    It  is  not  used  till  after  a  bath  for  cleansing  purposes  ;  and,  from 
the  night  when  such  "  purifying  "  bath  is  used,  Jewish  women  are  accustomed  to  calculate  the 
commencement  of  pregnancy.    That  you  should  not  have  heard  it  is  not  strange ;  its  mention 
would  be  considered  highly  indelicate. 

4.  Jewish  women  reckon  their  pregnancy  to  last  nine  calendar  or  ten  lunar  months— 270  to  2SO 
days.    There  are  no  special  data  on  which  to  reckon  an  average,  nor  do  I  know  of  any  books  on 
the  subject,  except  some  Talmuiic  authorities,  which  I  will  look  up  for  you  if  you  desire  it.    Pray 
make  no  apologies  for  writing  to  me :  any  information  I  possess  is  at  your  service. 

I  am,  dear  Sir,  yours  very  truly, 

DR.  PLAYFAIR.  A-  Aram. 

P.  S.— The  Biblical  foundation  for  the  law  of  the  seven  clear  days  is  Leviticus  xv.,  verse  19  till 
the^end  of  the  chapter— especially  verse  28. 

2  Rev.  de  Therap.  Med.-Chir.,  1867. 

3  American  Journal  of  Obstetrics,  Sept.  1891.  4  Ibid.,  1878,  vol.  xi.  p.  673. 


94  ORGANS    CONCERNED    IN    PARTURITION. 

general  condition  of  the  vascular  system,  specially  localizing  itself  in 
the  generative  organs,  and  connected  with  rhythmical  changes  in  their 
nerve-centres.  It  does  not  seem  to  me,  however,  that  he  has  satis- 
factorily proved  the  recurrence  of  the  conditions  which  his  ingenious 
theory  assumes.  The  purpose  of  the  loss  of  so  much  blood  is  also 
semewhat  obscure.  To  a  certain  extent  it  must  be  considered  an  acci- 
dent or  complication  of  ovulatioii,  produced  by  the  vascular  turgescence. 
Nor  is  it  essential  to  fecundation,  because,  women  often  conceive  during 
lactation,  when  menstruation  is  suspended ;  or  before  the  function  has 
become  established.  It  may,  however,  serve  the  negative  purpose  of 
relieving  the  congested  uterine  capillaries  which  are  periodically  filled 
with  a  supply  of  blood  for  the  great  growth  which  takes  place  wrhen 
conception  has  occurred.  Thus,  immediately  before  each  period  the 
uterus  may  be  considered  to  be  placed  by  the  afflux  of  blood  in  a  state 
of  preparation  for  the  function  it  may  suddenly  be  called  upon  to  per- 
form. That  the  discharge  relieves  a  state  of  vascular  tension  which 
accompanies  ovulation  is  proved  by  the  singular  phenomenon  of 
vicarious  menstruation  which  is  occasionally,  though  rarely,  met  with. 
It  occurs  in  cases  in  which,  from  some  unexplained  cause,  the  discharge 
does  not  escape  from  the  uterine  mucous  membrane.  Under  such  cir- 
cumstances a  more  or  less  regular  escape  of  blood  may  take  place  from 
other  sites.  The  most  common  situations  are  the  mucous  membranes 
of  the  stomach,  of  the  nasal  cavities,  or  of  the  lungs ;  -the  skin,  not 
uncommonly  that  of  the  mamma?,  probably  on  account  of  their  intimate 
sympathetic  relation  with  the  uterine  organs  ;  from  the  surface  of  an 
ulcer ;  or  from  hemorrhoids.  It  is  a  noteworthy  fact  that  in  all  these 
cases  the  discharge  occurs  in  situations  where  its  external  escape  can 
readily  take  place.  This  strange  deviation  of  the  menstrual  discharge 
may  be  taken  as  a  sign  of  general  ill-health,  and  it  is  usually  met  with 
in  delicate  young  women  of  highly  mobile  nervous  constitution.  It 
may,  however,  begin  at  puberty,  and  it  has  even  been  observed  during 
the  whole  sexual  life.  The  recurrence  is  regular,  and  always  in  con- 
nection with  the  menstrual  nisus,  although  the  amount  of  blood  lost  is 
much  less  than  in  ordinary  menstruation. 

Cessation  of  Menstruation. — After  a  certain  time  changes  occur, 
showing  that  the  woman  is  no  longer  fitted  for  reproduction  ;  men- 
struation ceases,  Graafiau  follicles  are  no  longer  matured,  and  the  ovary 
becomes  shrivelled  and  wrinkled  on  its  surface.  Analogous  alterations 
take  place  in  the  uterus  and  its  appendages.  The  Fallopian  tubes 
atrophy,  and  are  not  unfrequently  obliterated.  The  uterus  decreases 
in  size.  The  cervix  undergoes  a  remarkable  change,  which  is  readily 
detected  on  vaginal  examination  ;  the  projection  of  the  cervix  into  the 
vaginal  canal  disappears,  and  the  orifice  of  the  os  uteri  in  oil  women 
is  found  to  be  flush  with  the  roof  of  the  vagina.  In  a  large  number 
of  cases  there  is,  after  the  cessation  of  menstruation,  an  occlusion  both 
of  the  external  and  internal  os  ;  the  canal  of  the  cervix  between  them, 
however,  remains  patulous,  and  is  not  unfrequently  distended  with  a 
mucous  secretion. 

Period  of  Cessation. — The  age  at  which  menstruation  ceases  varies 
much  in  different  women.  -In  certain  cases  it  may  cease  at  an  unusually 


OVULATION    AND    MENSTRUATION.  95 

early  age,  as  between  thirty  and  forty  years,  or  it  may  continue  far 
beyond  the  average  time,  even  up  to  sixty  years ;  and  exceptional, 
though  perhaps  hardly  reliable,  instances  are  recorded,  in  which  it  has 
continued  even  to  eighty  or  ninety  years.  These  are,  however,  strange 
anomalies,  which,  like  cases  of  unusually  precocious  menstruation, 
cannot  be  considered  as  having  any  bearing  on  the  general  rule.  Most 
cases  of  so-called  protracted  menstruation  will  be  found  to  be  really 
morbid  losses  of  blood  depending  on  malignant  or  other  forms  of 
organic  disease,  the  existence  of  which,  under  such  circumstances, 
should  always  be  suspected. 

In  England  menstruation  usually  ceases  between  forty  and  fifty 
years  of  age.  Raciborski  says  that  the  largest  number  of  cases  of 
cessation  are  met  with  in  the  forty-sixth  year.  It  is  generally  said 
that  women  who  commence  to  menstruate  when  very  young  cease  to 
do  so  at  a  comparatively  early  age,  so  that  the  average  duration  of  the 
function  is  about  the  same  in  all  women.  Cazeaux  and  Raciborski, 
whose  opinion  is  strengthened  by  the  observations  of  Guy  in  1500 
cases,1  think,  on  the  contrary,  that  the  earlier  menstruation  commences 
the  longer  it  lasts,  early  menstruation  indicating  an  excess  of  vital 
energy  which  continues  during  the  whole  childbearing  life.  Climate 
and  other  accidental  causes  do  not  seem  to  have  as  much  effect  on  the 
cessation  as  on  the  establishment  of  the  function.  It  does  not  appear 
to  cease  earlier  in  warm  than  in  temperate  climates.  The  change  of 
life  is  generally  indicated  by  irregularities  in  the  recurrence  of  the 
discharge.  It  seldom  ceases  suddenly,  but  it  may  be  absent  for  one  or 
more  periods,  and  then  occur  irregularly ;  or  it  may  become  profuse 
or  scanty,  until  eventually  it  entirely  stops.  The  popular  notions  as 
to  the  extreme  danger  of  the  menopause  are  probably  much  exagger- 
ated ;  although  it  is  certain  that  at  that  time  various  nervous  phenomena 
are  apt  to  be  developed.  So  far  from  having  a  prejudicial  effect  on 
the  health,  however,  it  is  not  an  uncommon  observation  to  see  an 
hysterical  woman,  who  has  been  for  years  a  martyr  to  uterine  and 
other  complaints,  apparently  take  a  new  lease  of  life  when  her  uterine 
functions  have  ceased  to  be  in  active  operation  ;  and  statistical  tables 
abundantly  prove  that  the  general  mortality  of  the  sex  is  not  greater 
at  this  than  at  any  other  time. 

1  Med.  Times  and  Gaz.,  1845. 


PART  II. 

PREGNANCY. 


CHAPTER    I. 

CONCEPTION  AND  GENERATION. 

Generation  in  the  human  female,  as  in  all  mammals,  requires  the 
congress  of  the  two  sexes,  in  order  that  the  semen,  the  male  element 
of  generation,  may  be  brought  into  contact  with  the  ovule,  the  female 
element  of  generation. 

The  Semen. — The  semen  secreted  by  the  testicle  of  an  adult  male 
is  a  viscid,  opalescent  fluid,  forming  an  emulsion  when  mixed  with 
water,  and  having  a  peculiar  faint  odor,  which  is  attributed  to  the 
secretions  which  are  mixed  with  it,  such  as  those  from  the  prostate 
and  Cowper's  glands.  On  analysis  it  is  found  to  be  an  albuminous 
fluid,  holding  in  solution  various  salts,  principally  phosphates  and 
chlorides,  and  an  animal  substance,  spermatin,  analogous  to  fibrin. 
Examined  under  a  magnifying  power  of  from  400  to  500  diameters, 
it  consists  of  a  transparent  and  homogeneous  fluid,  in  which  are 
floating  a  certain  number  of  granules  and  epithelial  cells,  derived  from 
the  secretions  mixed  with  it,  and  certain  characteristic  bodies,  the 
spermatozoa,  which  are  developed  from  the  sperm  cells,  and  which 
form  its  essential  constituents.  The  sperm  cells  are  those  occupying 
the  tubuli  seminiferi  of  the  testicle.  Several  kinds  of  sperm  cells 
are  described,  which  receive  their  name  from  the  position  they  occupy 
with  regard  to  the  lumen  of  the  tubule  (Fig.  44).  The  cells  which 
are  next  to  the  wall  of  the  tubule  are  called  the  outer  or  lining  cells. 
They  are  more  or  less  flattened  in  form,  and  are  situated  on  a  distinct 
basement  membrane.  Internal  to  this  layer  is  another,  consisting  of 
round  cells,  the  nuclei  of  which  are  in  a  state  of  proliferation  ;  this  is 
the  intermediate  layer.  Between  this  and  the  lumen  of  the  tubule  are 
a  number  of  cells,  irregular  in  shape,  amongst  which  are  imbedded 
the  heads  of  the  spermatozoa,  the  tails  of  which  project  into  the  lumen. 
The  spermatozoa  are  thought  to  arise  from  the  middle  or  proliferating 
layer  in  the  following  manner :  the  nuclei  of  the  sperm  cells  pro- 
liferate, and  from  their  subdivisions  arise  the  heads  of  the  spermatozoa, 
the  bodies  of  which  originate  from  the  protoplasm  of  the  cells.  By 
the  decomposition  of  the  substance  in  which  the  heads  of  the  sperma- 
tozoa are  imbedded,  the  contained  spermatozoa  become  liberated,  and 
move  about  freely  in  the  seminal  fluid.  * 
96 


CONCEPTION    AND    GENERATION. 


97 


As  seen  under  the  microscope,  the  spermatozoa,  which  exist  in 
healthy  semen  in  enormous  numbers,  present  the  appearance  of  minute 
particles,  not  unlike  a  tadpole  in  shape.  The  head  is  oval  and  flat- 
tened, measuring  about  y^^-jjo-  of  an  inch  in  breadth,  and  attached  to 
it  by  a  short  intermediate  portion  is  a  delicate  filamentous  expansion 
or  tail,  which  tapers  to  a  point  so  fine  that  its  termination  cannot  be 
seen  by  the  highest  powers  of  the  microscope.  The  whole  sperma- 
tozoon measures  from  -^fa  to  -g-^-g-  of  an  inch  in  length.  The  sperma- 
tozoa are  observed  to  be  in  constant  motion,  sometimes  very  rapid, 
sometimes  more  gentle,  which  is  supposed  to  be  the  means  by  which 


FIG.  44. 


Section  of  parts  of  three  seminiferous  tubules  of  the  rat.  a.  With  the  spermatozoa  least  advanced 
in  development,  b.  More  advanced,  c.  Containing  fully-developed  spermatozoa.  Between  the 
tubules  are  seen  strands  of  interstitial  cells  and  lymph  spaces.  (From  a  preparation  by  MR.  A. 
FRAZER.) 

they  pass  upward  through  the  female  genital  organs.  They  retain 
their  vitality  and  power  of  movement  for  a  considerable  time  after 
einission,  provided  the  semen  is  kept  at  a  temperature  similar  to  that 
of  the  body.  Under  such  circumstances  they  have  been  observed  in 
active  motion  from  forty-eight  to  seventy-two  hours  after  ejaculation, 
and  they  have  also  been  seen  alive  in  the  testicle  as  long  as  twenty- 
four  hours  after  death.  In  all  probability  they  continue  active  much 
longer  within  the  generative  organs,  as  many  physiologists  have 
observed  them  in  full  vitality  in  bitches  and  rabbits,  seven  or  eight 
days  after  copulation.  The  recent  experiments  of  Haussman,  how- 
ever, show  that  they  lose  their  power  of  motion  in  the  human  vagina 
within  twelve  hours  after  coitus,  although  they  doubtless  retain  it 
longer  in  the  uterus  and  Fallopian  tubes.  Abundant  leucorrhoeal  dis- 
charges and  acrid  vaginal  secretions  destroy  their  movements,  and  may 
thus  cause  sterility  in  the  female.  On  account  of  their  mobility,  the 
spermatozoa  were  long  considered  to  be  independent  animalcules,  a 
view  which  is  by  no  means  exploded,  and  has  been  maintained  in 

7 


98  PREGXANCY. 

modern  times  by  Pouchet,  Jouliu,  and  other  writers,  while  Coste. 
Robin,  Kolliker,  etc.,  liken  their  motion  to  that  of  ciliated  epithelium. 
There  can  be  no  doubt  that  the  fertilizing  power  of  the  semen  is  due 
to  the  presence  of  the  spermatozoa,  although  some  of  the  older  physi- 
ologists assigned  it  to  the  spermatic  fluid.  The  former  view,  however, 
has  been  conclusively  proved  by  the  experiments  of  Prevost  and 
Dumas,  who  found  that  on  carefully  removing  the  spermatozoa  by 
filtration  the  semen  lost  its  fecundating  properties. 

Sites  of  Impregnation. — There  has  been  great  difference  of  opinion 
as  to  the  part  of  the  genital  tract  in  which  the  spermatozoa  and  the 
ovule  come  into  contact,  and  in  which  impregnation,  therefore,  occurs. 
Spermatozoa  have  been  observed  in  all  parts  of  the  female  genital 
organs  in  animals  killed  shortly  after  coitus,  especially  in  the  Fallopian 
tubes,  and  even  on  the  surface  of  the  ovary.  The  fact  that  fecundation 
has  been  proved  to  occur  in  certain  animals  within  the  ovary,  tends  to 
support  the  idea  that  it  may  also  occur  in  the  human  female  before  the 
rupture  of  the  Graafian  follicle.  In  order  to  do  so,  however,  it  is 
necessary  for  the  spermatozoa  to  penetrate  the  proper  structure  of  the 
follicle  and  the  epithelial  covering  of  the  ovary,  and  no  one  has  actu- 
ally seen  them  doing  so.  Most  probably  the  contact  of  the  spermatozoa 
and  the  ovule  occurs  very  shortly  after  the  rupture  of  the  follicle,  and 
in  the  outer  part  of  the  Fallopian  tubes.  Coste  maintains  that,  unless 
the  ovule  is  impregnated,  it  very  rapidly  degenerates  after  being 
expelled  from  the  ovary,  partly  by  inherent  changes  in  the  ovule 
itself,  and  partly  because  it  then  soon  becomes  invested  by  an  albu- 
minous covering  which  is  impermeable  to  the  spermatozoa.  He 
believes,  therefore,  that  impregnation  can  only  occur  either  on  the 
surface  of  the  ovary,  or  just  within  the  fimbriated  extremity  of  the 
tube. 

Mode  in  which  the  Ascent  of  the  Semen  is  Effected. — The  semen 
is  probably  carried  upward  chiefly  by  the  inherent  mobility  of  the 
spermatozoa.  It  is  believed  by  some  that  this  is  assisted  by  other 
agencies :  amongst  them  are  mentioned  the  peristalti ;  action  of  the 
uterus  and  Fallopian  tubes  ;  a  sort  of  capillary  attraction  effected  when 
the  walls  of  the  uterus  are  in  close  contact,  similar  to  the  movement  of 
fluid  in  minute  tubes ;  and  also  the  vibratile  action  of  the  cilia  of  the 
epithelium  of  the  uterine  mucous  membrane.  The  action  of  the  latter 
is  extremely  doubtful,  for  they  are  also  supposed  to  effect  the  descent 
of  the  ovule,  and  they  can  hardly  act  in  two  opposite  ways.  The 
movement  of  the  cilia  being  from  within  outward,  it  would  certainly 
oppose  rather  than  favor  the  progress  of  the  spermatozoa.  It  must. 
therefore,  be  admitted  that  they  ascend  chiefly  through  their  own 
powers  of  motion.  They  certainly  have  this  power  to  a  remarkable 
extent,  for  there  are  numerous  cases  on  record  in  which  impregnation 
has  occurred  without  penetration,  and  even  when  the  hymen  was  quite 
entire,  and  in  which  the  semen  has  simply  been  deposited  on  the 
exterior  of  the  vulva ;  in  such  cases,  which  are  far  from  uncommon, 
the  spermatozoa  must  have  found  their  way  through  the  whole  length 
of  the  vagina.  It  is  probable,  however,  that  under  ordinary  circum- 
stances the  passage  of  the  spermatic  fluid  into  the  uterus  is  facilitated 


CONCEPTION    AND    GENERATION. 


99 


FIG.  45. 


by  changes  which  take  place  in  the  cervix  during  the  sexual  orgasm,  in 
the  course  of  which  the  os  uteri  is  said  to  dilate  and  close  again  in  a 
rhythmical  manner.1 

Impregnation. — The  precise  method  in  which  the  spermatozoa  effect 
impregnation  was  long  a  matter  of  doubt.  It  is  now,  however,  certain 
that  they  actually  penetrate  the  ovule,  and  reach  its  interior.  This  has 
been  conclusively  proved  by  the  observations  of  Barry,  Meissner,  and 
others,  who  have  seen  the  spermatozoa  within  the  external  membrane 
of  the  ovule  in  rabbits  (Fig.  45).  In  some  of  the  invertebrata  a  canal 
or  opening,  called  the  micropyle,  exists  in  the  zona  pellucida,  through 
which  the  spermatozoa  pass.  No  such  aperture  has  yet  been  demon- 
strated in  the  ovules  of  mammals,  but  its  existence  is  far  from  improb- 
able. According  to  the  observations  of  Newport,  several  spermatozoa 
penetrate  the  zona  pellucida  and  enter  the  ovule,  and  the  greater  the 
number  that  do  so  the  more  certain  fecundation  becomes.  In  the  lower 
animals  the  fusion  of  the  spermatozoa  with  the  substance  of  the  yelk 
has  been  observed,  and  although  similar  phenomena  have  not  been  de- 
tected in  the  human  ovum,  there  is  not  any  doubt  but  that  the  further 
development  of  the  ovum  is  due  to  the  union  of  the  spermatozoa  with 
the  female  element. 

The  length  of  time  which  elapses  before  the  fecundated  ovule  arrives 
in  the  cavity  of  the  uterus  has  not  yet  been  ascertained,  and  it  probably 
varies  under  different  circumstances.     It  is 
known  that  in  the  bitch  it  may  remain  eight 
or  ten  days  in  the  Fallopian  tube,  in  the 
guinea-pig  three  or  four.     In  the  human 
female  the  ovum  has  never  been  discovered 
in  the  cavity  of  the  uterus  before  the  tenth 
or  twelfth  day  after  impregnation. 

The  changes  which  occur  in  the  human 
ovule  immediately  before  and  after  impreg- 
nation, and  during  its  progress  through  the 
Fallopian  tube,  are  only  known  to  us  by 
analogy,  as,  of  course,  it  is  impossible  to 
study  them  by  actual  observation.  We  are 
in  possession,  however,  of  accurate  informa- 
tion of  what  has  been  made  out  in  the  lower 
animals,  and  it  is  reasonable  to  suppose 
that  similar  changes  occur  in  man.  Imme- 
diately after  the  ovule  has  passed  into  the  Fallopian  tube,  it  is  found  to 
be  surrounded  by  a  layer  of  granular  cells,  a  portion  of  the  lining 
membrane  of  the  Graafian  follicle,  which  was  described  as  the  discus 
proligerus.  As  it  proceeds  along  the  tube  these  surrounding  cells  dis- 
appear, partly,  it  is  supposed,  by  friction  on  the  walls  of  the  tube,  and 
partly  by  being  absorbed  to  nourish  the  ovule.  Be  this  as  it  may, 
before  long  they  are  no  longer  observed,  and  the  zona  pellucida  forms 
the  outermost  layer  of  the  ovule.  When  the  ovule  has  advanced  some 
distance  along  the  tube,  it  becomes  invested  with  a  covering  of  albu- 

i  "  How  do  the  Spermatozoa  Enter  the  Uterus  ?  "    By  J.  Beck,  M.D. 


Ovum  of  rabbit  containing  sper- 
matozoa. 1.  Zona  pellucida.  2.  The 
germ,  consisting  of  two  large  cells, 
several  smaller  cells,  and  sperma- 
tozoa. 


100  PREGNANCY. 

minous  material,  which  is  deposited  around  it  iu  successive  layers,  the 
thickness  of  which  varies  in  different  animals.  It  is  very  abundant 
in  birds,  in  whom  it  forms  the  familiar  white  of  the  egg.  In  some 
animals  it  has  not  been  detected,  so  that  its  presence  in  the  human 
ovule  is  uncertain.  Where  it  exists  it  doubtless  contributes  to  the 
nourishment  of  the  ovule. 

Coincident  with  these  changes  is  the  disappearance  of  the  germinal 
vesicle.  At  the  same  time  the  yelk  contracts  and  becomes  more  solid ; 
retiring  from  close  contact  with  the  zona  pellucida,  and  thus  leaving 
a  space,  between  the  outer  edge  of  the  yelk  and  the  vitelline  membrane, 

which   in   some   animals  is  filled  with 
FIG.  46.  a  transparent  liquid.     Coincident  with 

the  shrinking  of  the  yelk,  a  small  gran- 
ular mass  of  a  rounded  form  is  ex- 
truded from  the  yelk  into  the  clear  space 
beneath  the  zona  pellucida.  At  a  later 
period  another  similar  mass  is  extruded. 
These  are  the  polar  globules  (Fig.  46),  and 
it  is  thought  from  observations  on  the 
invertebrata  that  they  arise  from  the 
germinal  vesicle,  the  remains  of  which 
gives  origin  to  a  new  nucleus,  which 
Formation  of  the  "polar  globule."  jg  fcuown  as  the  female  pro-nucleus. 

1.  Zona  pellucida,  containing  sperma-      m,  -,  •  11  i 

tozoa.    2.   Yelk      3  and  4.   Germinal      These     changes      OCClir     111     all     OVllleS, 

vesicle.  5.  The  polar  globule.  whether  they  are  impregnated  or  not, 

but  if  the  ovule  is  not  fecundated,  no 

further  alterations  occur.  Supposing  impregnation  has  taken  place 
by  the  entrance  of  a  spermatozoon  within  the  zoua  pellucida  of  the 
ovule,  a  second  nucleus  is  formed  by  the  penetration  of  a  spermatozoon 
within  the  yelk,  where  it  loses  its  tail  and  becomes  transformed  into 
a  granular  body,  the  male  pro-nucleus.  After  a  time  the  male  and 
female  pro-nuclei  approach  one  another  and  finally  fuse  to  form  a  new 
nucleus,  and  the  ovum  then  receives  the  name  of  the  Blastosphere.  or 
first  segmentation  sphere. 

After  this  occurs  the  very  peculiar  phenomenon  known  as  the 
cleavage  of  the  yelk,  which  results  in  the  formation  of  the  layer  of 
cells  from  which  the  foetus  is  developed.  The  segmentation  of  the 
yelk  (Fig.  47)  occupies  in  mammals  the  whole  of  its  substance.  In 
birds  the  cleavage  is  confined  to  a  small  area  of  the  yelk  called  the 
cicatricula  or  blastoderm.  Hence  the  term  Holoblastic  has  been  applied 
to  the  ova  of  mammals,  Meroblastic  to  those  of  birds.  It  divides  at 
first  into  two  halves,  and  at  the  same  time  the  ne\v  or  first  segmenta- 
tion nucleus  becomes  constricted  in  its  centre,  and  separates  into  two 
portions,  one  of  which  forms  a  centre  for  each  of  the  halves  into  which 
the  yelk  has  divided.  Each  of  these  immediately  divides  into  two,  as 
does  its  contained  portion  of  the  nucleus,  and  so  on  in  rapid  succession 
until  the  whole  yelk  is  divided  into  a  number  of  divisions,  each  of 
which  consists  of  a  clump  of  nucleated  protoplasm. 

By  these  continuous  dichotomous  divisions  the  whole  yelk  is  formed 
into  a  granular  mass,  which,  from  its  supposed  resemblance  to  a  niul- 


CONCEPTION    AND    GENERATION. 


101 


berry,  has  been  named  the  muriform  body.  When  the  subdivision  of 
the  yelk  is  completed,  its  separate  parts  become  converted  into  a  num- 
ber of  cells,  each  of  which  consists  of  a  mass  of  granular  protoplasm. 
These  cells  unite  by  their  edges  to  form  a  continuous  lining  (Fig.  48), 
which,  through  the  expansion  of  the  muriform  body  by  fluid  which 
forms  in  its  interior,  is  distended  until  it  forms  a  lining  to  the  zona 
pellucida.  This  is  the  blastodermic  membrane,  from  which  the  foetus 
i*5  developed.  By  this  time  the  ovum  has  reached  the  uterus,  and, 


FIG.  47. 


ect 


zp. 


Sections  of  the  ovum  of  the  rabbit  during  the  later  stages  of  segmentation,  showing  the  formation 
of  the  blastodermic  vesicle,  a.  Section  showing  the  enclosure  of  entomeres,  mi. ,  by  ectomeres,  ect. , 
except  at  one  spot— the  blastopore.  b.  More  advanced  stage,  in  which  fluid  is  beginning  to 
accumulate  between  the  entomeres  and  ectomeres,  the  former  completely  enclosed,  c.  The  fluid  has 
much  increased,  so  that  a  large  space  separates  entomeres  from  ectomeres,  except  at  one  part, 
rf.  Blastodermic  vesicle,  its  wall  formed  of  a  layer  of  ectodermic  cells,  with  a  patch  of  entomeres 
adhering  to  it  at  one  part,  z.p.,  ect.,  ent.  As  before.  (After  E.  v.  BENEDEN.) 

before  proceeding  to  consider  the  further  changes  which  it  undergoes, 
it  will  be  well  to  study  the  alteration  which  the  stimulus  of  impregna- 
tion has  set  on  foot  in  the  mucous  membrane  of  the  uterus,  in  order  to 
prepare  it  for  the  reception  and  growth  of  its  contents. 

Even  before  the  ovum  reaches  the  uterus,  the  mucous  membrane 
becomes  thickened  and  vascular,  so  that  its  opposing  surfaces  entirely 
fill  the  uterine  cavity.  These  changes  may  be  said  to  be  the  same  in 
kind,  although  more  marked  and  extensive  in  degree,  as  the  alterations 


102  PREGNANCY. 

which  take  place  in  the  mucous  membrane  in  connection  with  each 
menstrual  period.  The  result  is  the  formation  of  a  distinct  membrane, 
which  affords  the  ovum  a  safe  anchorage  and  protection,  until  its  con- 
nections with  the  uterus  are  more  fully  developed.  After  delivery, 
this  membrane,  which  is  by  that  time  quite  altered  in  appearance,  is 
at  least  partially  thrown  off  with  the  ovum  ;  on  which  account  it  has 
received  the  name  of  the  decidua  or  caduca. 


FIG.  48. 


Formation  of  the  blasted ermic  membrane  from  the  cells  of  the  muriform  body.    1.  Layer  of 
albuminous  material  surrounding  2.  The  zona  pellucida.    (After  JOULIN.) 

The  decidua  consists  of  two  principal  portions,  which,  in  early 
pregnancy,  are  separated  from  each  other  by  a  considerable  interspace, 
which  is  occupied  by  mucus.  One  of  these,  called  the  decidua  vera, 
lines  the  entire  uterine  cavity,  and  is,  no  doubt,  the  original  mucous 
lining  of  the  uterus  greatly  hypertrophied.  The  second,  the  decidua 
reflexa,  is  closely  applied  round  the  ovum  ;  and  it  is  probably  formed 
by  the  sprouting  of  the  decidua  vera  around  the  ovum  at  the  point  on 
which  the  latter  rests,  sx>  that  it  eventually  completely  surrounds  it. 
As  the  ovum  enlarges,  the  decidua  reflexa  is  necessarily  stretched, 
until  it  comes  everywhere  into  contact  with  the  decidua  vera,  with 
which  it  firmly  unites.  After  the  third  month  of  pregnancy  true 
union  has  occurred,  and  the  two  layers  of  decidua  are  no  longer 
separate.  The  decidua  serotina,  which  is  described  as  a  third  portion, 
is  merely  that  part  of  the  decidua  vera  on  which  the  ovum  rests,  and 
where  the  placenta  is  eventually  developed  ;  it  is  characterized  by  its 
extreme  vascularity,  which  serves  the  purpose  of  supplying  nutriment 
to  the  foetus  through  the  capillaries  of  the  foetal  placenta. 

It  is  needless  to  refer  at  length  to  the  various  views  which  have 
been  held  by  anatomists  as  to  the  structure  and  formation  of  the  de- 
cidua. That  taught  by  John  Hunter  was  long  believed  to  be  correct, 
and  down  to  a  recent  date  it  received  the  adherence  of  most  physiolo- 


CONCEPTION    AND    GENERATION. 


103 


gists.  He  believed  the  decidua  to  be  an  inflammatory  exudation 
which,  on  account  of  the  stimulus  of  pregnancy,  was  thrown  out  all 
over  the  cavity  of  the  uterus,  and  soon  formed  a  distinct  lining  mem- 
brane to  it.  When  the  ovum  reached  the  uterine  orifice  of  the  Fal- 
lopian tube  it  found  its  entrance  barred  by  this  new  membrane,  which 
accordingly  it  pushed  before  it.  This  separated  portion  formed  a 
covering  to  the  ovum,  and  became  the  decidua  reflexa,  while  a  fresh 
exudation  took  place  at  that  portion  of  the  uterine  wall  which  was 
thus  laid  bare,  and  this  became  the  decidua  serotina.  William  Hunter 
had  much  more  correct  views  of  the  decidua,  the  accuracy  of  which 
was  at  the  time  much  contested,  but  which  have  recently  received  full 
recognition.  He  describes  the  decidua  in  his  earlier  writings  as  an 
hypertrophy  of  the  uterine  mucous  membrane  itself,  a  view  which  is 
now  held  by  all  physiologists. 

When  the  decidua  is  first  formed  it  is  a  hollow  triangular  sac  lining 
the  uterine  cavity  (Fig.  49),  and  having  three  openings  into  it  those 

FIG.  49. 


Aborted  ovum  of  about  forty  days,  showing  the  triangular  shape  of  the  decidua  (which  is 
laid  open),  and  the  aperture  of  the  Fallopian  tube.    (After  COSTE.) 

of  the  Fallopian  tubes  at  its  upper  angles,  and  one,  corresponding^  to 
the  internal  os  uteri,  below.  If,  as  is  generally  the  ease,  it  is  thick 
and  pulpy,  these  openings  are  closed  up,  and  can  no  longer  be  detected. 
In  early  pregnancy  it  is  well  developed,  and  continues  to  grow  up  to 
the  third  month  of  utero-gestation.  After  that  time  it  commences  to 
atrophy,  its  adhesion  with  the  uterine  walls  lessens,  it  becomes  thin 
and  transparent,  and  is  ready  for  expulsion  when  delivery  is  effected. 
When  it  is  most  developed,  a  careful  examination  of  the  decidua 
enables  us  to  detect  in  it  all  the  elements  of  the  uterine  mucous  mem- 
brane greatly  hypertrophied.  Its  substance  chiefly  consists  of  large 


PREGNANCY. 


round  or  oval  nucleated  cells  and  elongated  fibres,  mixed  with  the 
tubular  uterine  glands,  which  are  much  elongated,  lined  by  columnar 
ciliated  epithelial  cells,  and  contain  a  small  quantity  of  milky  fluid. 
According  to  Friedlandcr,  the  decidua  is  divisible  into  two  layers : 
the  inner  being  formed  by  a  proliferation  of  the  corpuscles  of  the  sub- 
epithelial  connective  tissue  of  the  mucous  membrane;  the  deeper,  in 
contact  with  the  uterine  walls,  out  of  flattened  or  compressed  gland 
ducts.  In  an  early  abortion  the  extremities  of  these  ducts  may  be 
observed  by  a  lens  on  the  external  or  uterine  surface  of  the  decidua, 
occupying  the  summit  of  minute  projections,  separated  from  each  other 
by  depressions.  If  these  projections  be  bisected  they  will  be  found  to 
contain  little  cavities,  filled  with  lactescent  fluid,  which  were  first 
described  by  Montgomery,  of  Dublin,  and  are  known  as  Montgomery's 
cups.  They  are  in  fact  the  dilated  canals  of  the  uterine  tubular 
glands.  On  the  internal  surface  of  such  an  early  decidua  a  number 
of  shallow  depressions  may  be  made  out,  which  are  the  open  mouths 
of  these  ducts. 


FIG.  50. 


FIG.  51. 


FIG.  52. 


Formation  of  decidua.  (The 
decidua  is  colored  black, 
the  ovum  is  represented  as 
engaged  between  two  project- 
ing folds  of  membrane.) 


Projecting  folds  of  membrane 
growing  up  around  the  ovum. 
(After  DALTON.) 


Showing  ovum  completely 
surrounded  by  the  decidua 
reflexa. 


The  decidua  vera  is  highly  vascular,  and  its  vascularity  persists  till 
after  the  seventh  month  of  pregnancy ;  the  decidua  reflexa  is  only 
vascular  during  the  early  part  of  pregnancy,  depending  for  its  vas- 
cularity chiefly  on  the  villi  of  the  chorion,  and  hence  losing  this  with 
their  atrophy. 

When  the  ovum  reaches  the  uterine  cavity  it  soon  becomes  imbedded 
in  the  folds  of  the  hypertrophied  mucous  membrane,  which  almost 
entirely  fills  the  uterine  cavity.  As  a  rule  it  is  attached  to  some  point 
near  the  opening  of  a  Fallopian  tube,  the  swollen  folds  of  mucous 
membrane  preventing  its  descent  to  the  lower  part  of  the  uterus  ;  in 
exceptional  circumstances,  however — as  in  women  who  have  borne 
many  children,  and  have  a  more  than  usually  dilated  uterine  cavity — 
it  may  fix  itself  at  a  point  much  nearer  the  internal  os  uteri.  Accord- 
ing to  the  now  generally  accepted  opinion  of  Coste,  the  mucous  mem- 
brane at  the  base  of  the  ovum  soon  begins  to  sprout  around  it,  and 


CONCEPTION    AND    GENERATION. 


105 


gradually  extends  until  it  eventually  covers  the  ovuin  (Figs.  50-52), 
and  forms  the  decidua  reflexa.  Coste  describes,  under  the  name  of 
the  umbilicus,  a  small  depression  at  the  most  prominent  part  of  the 
ovum,  which  lie  considers  to  be  the  indication  of  the  point  where  the 
closure  of  the  decidua  reflexa  is  effected.  There  are  some  objections 
to  this  theory,  for  no  one  has  seen  the  decidua  reflexa  incomplete  and 
in  the  process  of  formation,  and  on  examining  its  external  surface, 
that  is,'  the  one  farthest  from  the  ovum,  its  microscopical  appearance 
is  identical  with  that  of  the  inner  surface  of  the  decidua  vera.  To 
meet  these  difficulties,  Weber  and  Goodsir,  whose  views  have  been 
adopted  by  Priestley,  contended  that  the  decidua  reflexa  is  "the 
primary  lamina  of  the  mucous  membrane,  which,  when  the  ovum 
enters  the  uterus,  separates  in  two-thirds  of  its  extent  from  the  layers 
beneath  it  to  adhere  to  the  ovum ;  the  remaining  third  remains  at- 
tached, and  forms  a  centre  of  nutrition."  According  to  this  view  the 
decidua  vera  would  be  a  subsequent  growth  over  the  separated  por- 
tion, and  the  decidua  serotina  the  portion  of  the  primary  lamina  which 
remained  attached.  In  this  way  the  fact  of  the  opposed  surfaces  of 
the  decidua  vera  and  reflexa  being  identical  in  structure  would  be 
accounted  for.  The  difficulty  which  this  theory  is  intended  to  meet 
does  not  seem  so  great  as  is  supposed,  for  if,  as  is  likely,  it  is  only  the 
epithelial  or  internal  surface  of  the  mucous  membrane  which  sprouts 
over  the  ovum,  and  not  its  deeper  layers,  the  facts  of  the  case  would 
be  sufficiently  met  by  Coste's  view. 


FIG.  53. 


An  ovum  removed  from  uterus,  and  part  of  the  decidua  vera  cut  away.  a.  Decidua  vera, 
showing  the  follicles  opening  on  its  inner  surface,  b.  Inner  extremity  of  Fallopian  tube. 
c.  Flap  of  decidua  reflexa.  d.  Ovum.  (After  COSTE.) 

Up  to  the  third  month  of  pregnancy  the  decidua  reflexa  and  vera 
are  not  in  close  contact,  and  there  may  even  be  a  considerable  inter- 
space between  them,  which  sometimes  contains  a  small  quantity  of 
mucous  fluid,  called  the  hydroperione.  This  fact  may  account  for  the 
curious  circumstance,  of  which  many  instances  are  on  record,  that  a 


106  PREGNANCY. 

uterine  sound  may  be  passed  into  a  gravid  uterus  in  the  early  months 
of  pregnancy  without  necessarily  producing  abortion,  and  also  for  the 
occasional  occurrence  of  menstruation  after  conception  (Figs.  53  and 
81).  Eventually,  by  the  growth  of  the  ovum,  the  decidua  reflexa 
comes  closely  into  contact  with  the  vera,  and  the  two  become  intimately 
blended  and  inseparable.  The  inner  surface  of  the  decidua  reflexa 
blends  with  the  outer  surface  of  the  chorion,  so  that  at  birth  the  decidua 
vera,  the  decidua  reflexa,  and  the  chorion  are  represented  by  one  mem- 
brane. 

As  pregnancy  advances  the  decidua  alters  in  appearance  and  becomes 
fibrous  and  thin.  In  the  later  months  of  utero-gestation  fatty  degenera- 
tion of  its  structure  commences,  its  vessels  and  glands  are  obliterated, 
and  its  adhesion  to  the  uterine  walls  is  lessened,  so  as  to  prepare  it  for 
separation.  As  we  shall  subsequently  see,  this  fatty  degeneration  was 
assumed  by  Simpson  to  be  the  determining  cause  of  labor  at  term. 
After  the  eighth  month,  thrombi  form  in  the  veins  lying  underneath 
the  decidua  serotina,  and  at  the  end  of  pregnancy  they  are  described 
by  Leopold1  as  having  become,  to  a  great  extent,  obliterated.  This, 
he  supposes,  may  have  some  effect  in  inducing  the  contractions  of  the 
uterus  in  labor. 

It  was  long  believed  that  the  entire  decidua  was  thrown  off  after 
labor,  leaving  the  muscular  coat  of  the  uterus  bare  and  denuded,  and 
that  a  new  mucous  membrane  was  formed  during  convalescence.  Ac- 
cording to  Robin,2  whose  views  are  corroborated  by  Priestley,  no  such 
denudation  of  the  muscular  tissue  of  the  uterus  ever  occurs,  but  a  por- 
tion of  the  decidua  always  remains  attached  after  delivery.  After  the 
fourth  month  of  pregnancy,  they  believe,  a  new  mucous  membrane 
is  formed  under  the  decidua,  which  remains  in  a  somewhat  imperfect 
condition  till  after  delivery,  when  it  rapidly  develops  and  assumes  the 
proper  functions  of  the  mucous  lining  of  the  uterus.  Robin  also  be- 
lieves that  that  portion  of  the  decidua  which  covers  the  placental  site, 
the  so-called  decidua  serotina,  is  not  thrown  off  with  the  membranes, 
like  the  decidua  vera  and  reflexa,  but  remains  attached  to  the  uterine 
walls,  a  thin  layer  of  it  only  being  expelled  with  the  placenta,  on  which 
it  may  be  observed.  Duncan3  entirely  dissents  from  these  views,  and 
does  not  admit  the  formation  of  a  new  mucous  membrane  during  the 
later  months  of  utero-gestatiou.  He  believes  that  the  greater  portion 
of  the  decidua  is  thrown  off,  but  that  part  remains,  and  from  this  the 
fresh  mucous  membrane  is  developed.  This  view  is  similar  to  that  of 
Spiegelberg,  who  holds  that  the  portion  of  the  decidua  that  is  expelled 
is  the  more  superficial  of  the  two  layers  described  by  Friedlander,  com- 
posed chiefly  of  the  epithelial  elements,  while  the  deeper  or  glandular 
layer  remains  attached  to  the  walls  of  the  uterus.  From  the  epithelium 
of  the  glands  a  new  epithelial  layer  is  rapidly  developed  after  delivery. 
Leopold*  has  shown  that  the  uterine  mucous  membrane  is  completely 
re-formed  within  six  weeks  after  delivery,  and  that  its  regeneration  is 

1  Arch.  f.  Gyn.,  1877,  Bd.  xi.,  Heft  3,  S.  443.    "Studien  liber  die  Uterus-schleimhaut  wahrend 
Menstruation." 

2  Memoires  del'Acad.  Imp.  de  MC>d  ,  1861. 
8  Researches  in  Obstetrics,  p.  186  et  seq. 

*  Arch.  f.  Gyn.,  1877,  Bd.  xii.,  Heft  2,  S.  169. 


CONCEPTION    AND    GENERATION.  107 

sometimes  completed  as  early  as  the  end  of  the  third  week.  This 
theory  bears  on  the  well-known  analogy  of  the  uterus  after  delivery 
to  the  stump  of  an  amputated  limb,  an  old  simile,  principally  based 
on  the  erroneous  theory  that  the  whole  muscular  tissue  of  the  uterus 
was  laid  bare.  This,  as  we  have  seen,  is  not  the  case,  but  the  simile  so 
far  holds  good  in  that  the  mucous  lining  is  deprived  of  its  epithelial 
covering ;  and  this  fact,  together  with  the  existence  of  numerous  open 
veins  on  the  interior  of  the  uterus,  readily  explains  the  extreme  sus- 
ceptibility to  septic  absorption,  which  forms  so  peculiar  a  characteristic 
of  the  puerperal  state. 

Before  we  commenced  the  study  of  the  decidua  we  had  traced  the 
impregnated  ovum  into  the  uterine  cavity,  and  described  the  formation 
of  the  blastodermic  membrane  by  the  junction  of  the  cells  of  the  muri- 
form  body.  We  must  now  proceed  to  consider  the  further  changes 
which  result  in  the  development  of  the  foetus,  and  of  the  membranes 
that  surround  it.  It  would  be  quite  out  of  place  in  a  work  of  this 
kind  to  enter  into  the  subject  of  embryology  at  any  length,  and  we 
must  therefore  be  content  with  such  details  as  are  of  importance  from 
a  practical  point  of  view. 

The  blastodermic  membrane,  which  forms  a  complete  spherical  lining 
to  the  ovum,  between  the  yelk  and  the  zona  pellucida,  soon  divides 
into  two  layers,  of  which  the  external  is  called  the  epiblast,  the  internal 
the  hypoblast,  and  between  these  is  subsequently  developed  a  third  layer, 
known  as  the  mesoblast.  From  these  three  layers  are  formed  the  entire 
foetus :  the  epiblast  giving  origin  to  the  central  nervous  system,  to  the 
superficial  layer  of  the  skin,  and  aiding  in  formation  of  the  organs  of 
special  sense,  and  of  the  amnion ;  the  hypoblast  forming  the  epithelial 
lining  membrane  of  the  alimentary  and  respiratory  tracts,  and  of  the 
tubes  and  glands  in  connection  with  them,  and  helping  in  the  develop- 
ment of  the  yelk  sac ;  the  mesoblast  giving  rise  to  the  skeleton,  the 
muscles,  the  connective  tissues,  the  vascular  system,  the  genito-urinary 
organs,  and  taking  part  in  the  formation  of  all  the  membranes. 

Almost  immediately  after  the  separation  of  the  blastodermic  mem- 
brane into  layers,  one  part  of  it  becomes  thickened  by  the  aggregation 
of  cells,  and  is  called  the  area  germinativa.  This  is  at  first  round  and 
then  oval  in  shape,  and  at  its  margin  the  first  indication  of  the  embryo 
may  be  detected  in  the  form  of  a  narrow  thickening,  the  primitive  trace. 
This  becomes  elongated,  and  stretches  in  a  strap-like  form  along  the 
centre  of  the  germinal  area;  it  is  considered  by  Balfour  to  represent 
the  Blastopore  of  animals,  the  ova  of  which  undergo  invagination  to. 
form  a  Gastrula.  Surrounding  it  are  some  cells  more  translucent  than 
those  of  the  rest  of  the  area  germinativa,  and  hence  called  the  area 
pellucida  (Fig.  54).  In  front  of  the  primitive  trace  two  elevated  ridges 
soon  arise,  the  laminae  dorsales,  which  include  between  them  a  groove, 
the  medullary  groove,  and  gradually  unite  posteriorly  to  form  a  cavity 
within  which  the  cerebro-spinal  axis  is  subsequently  developed.  The 
medullary  groove  as  it  grows  backward  overlaps  the  primitive  trace, 
which  disappears.  The  embryo  is  differentiated  from  the  rest  of  the 
blastoderm  by  a  fold  anteriorly,  which  is  called  the  cephalic  or  head 
fold.  Another  fold  afterward  appears  posteriorly,  which  is  called  the 


108  PREGNANCY. 

caudal  or  tail  fold.  Laterally,  folds  also  arise.  These  folds  all  tend 
to  grow  toward  the  centre  of  the  under  surface  of  what  will  be  the 
embryo. 

The  mesoblastic  layer  of  the  blastoderm,  except  that  part  which 
forms  the  axis  of  the  embryo,  splits  into  an  upper  layer,  the  somato- 
pleure,  which  is  beneath  the  epiblast,  and  a  lower  layer,  the  splanchuo- 
pleure,  which  lies  upon  the  hypoblast.  The  space  formed  by  this 
cleavage  of  the  mesoblast  is  called  the  pleuro-peritoneal  cavity.  The 
somato-pleure  is  engaged  in  the  formation  of  the  body  walls  of  the 
embryo.  The  splanchno-pleure  forms  the  walls  of  the  alimentary 
tract. 

FIG.  54. 


Diagram  of  area  germinativa,  showing  the  primitive  trace  and  area  pellucida. 

Formation  of  the  Amnion. — Processes  arise  from  the  somato- 
pleure  anteriorly,  posteriorly,  and  laterally,  which  gradually  arch  over 
the  dorsal  surface  of  the  foetus,  until  they  meet  each  other  and  form  a 
complete  envelope  to  it.  At  the  ventral  surface  these  processes  are 
separated  by  the  whole  length  of  the  embryo,  but  they  here  also  gradu- 
ally approach  each  other,  and  eventually  surround  what  is  subsequently 
the  umbilical  cord,  and  blend  with  the  integument  of  the  foetus  at  the 
point  of  its  insertion.  In  this  way  is  formed  the  amnion  (Fig.  55), 
consisting  of  two  layers:  the  internal,  derived  from  the  epiblast,  is 
formed  of  tessellated  epithelial  cells;  the  external,  arising  from  the 
mesoblast,  is  formed  of  cells  like  those  of  young  connective  tissue. 
Before  the  folds  of  the  amnion  unite,  the  free  edge  of  each  is  bent  out- 
ward and  spreads  around  the  ovum,  immediately  within  the  zona 
pellucida,  forming  a  lining  to  it,  termed  by  Turner  the  sub-zonal  mem- 
brane, which  is  connected  with  the  development  of  the  chorion.  In 
man  this  reflected  layer,  or  false  amnion,  consists  only  of  epiblast,  but 
in  some  other  animals  it  is  probably  formed  from  both  the  mesoblast 
and  the  epiblast,  like  the  true  amnion.  The  amnion  is  the  most  in- 
ternal of  the  membranes  surrounding  the  foetus,  and  will  presently  be 
studied  more  in  detail.  It  soon  becomes  distended  with  fluid,  the 
liquor  amnii,  and  as  this  increases  in  amount  it  separates  the  amnion 
more  and  more  from  the  foetus. 

During;  this  time  the  innermost  laver  of  the  blastodermic  membrane 

O  • 


CONCEPTION    AND    GENERATION. 


109 


or  hypoblast  is  also  developing  two  projections  at  either  extremity  of 
the  fetus,  and  these  gradually  approach  each  other  anteriorly.  As 
the  hypoblast  is  in  contact  with  the  yelk,  when  these  meet  they  have 


FIG  55. 


Development  of  the  amnion.  1.  Vitelline 
membrane.  2.  External  layer  of  blastodermic 
membrane.  3.  Internal  layers  forming  the 
umbilical  vesicle.  4.  Umbilical  vessels.  5. 
Projections  forming  amnion.  6.  Embryo. 
7.  Allantois. 


FIG.  56. 


1.  Exochorion.  2.  External  layer  of  blasto- 
dermic membrane.  3.  Umbilical  vesicle.  4.  Its 
vessels.  5.  Amnion.  6.  Embryo.  7.  Allantois 
increasing  in  size. 


the  effect  of  dividing  the  yelk  into  two  portions.  One,  and  the 
smaller  of  the  two,  forms  eventually  the  intestinal  canal  of  the  fetus ; 
the  other,  and  much  the  larger,  contains  the  greater  portion  of  the 


FIG.  57. 


Flo.  58. 


An  embryo  of  about  twenty-five 
days  laid  open.  a.  Chorion.  6.  Am- 
nion. c.  Cavity  of  chorion.  d.  Um- 
bilical vesicle,  e.  Pedicle  of  allan- 
tois.  /.  Embryo.  (After  COSTE  ) 


1.  Exochorion.  2.  External  layer  of  the  blasto- 
dermic membrane.  3.  Allantois.  4.  Umbilical  vesicle. 
5.  Amnion.  6.  Embryo.  7.  Pedicle  of  allantois. 


yelk,  and  forms  the  ephemeral  structure  known  as  the  umbilical  vesicle, 
from  which  the  fetus  derives  most  of  its  nourishment  during  the 
earlv  statre  of  its  existence.  Its  communication  with  the  abdominal 


110  PREGNANCY. 

cavity  of  the  foetus  is  through  the  constricted  portion  at  the  point  of 
division  called  the  vitdline  duct  (Fig.  56).  An  artery  and  vein,  the 
omphalo-mesenteric,  ramify  on  the  vesicle  and  its  duct. 

As  the  amnion  increases  in  size,  it  pushes  back  the  umbilical  vesicle 
toward  the  external  membrane  of  the  ovum,  between  which  and  the 
amnion  it  lies  (Fig.  57) ;  and  when  the  allantois  is  developed,  it  ceases 
to  be  of  any  use,  and  rapidly  shrinks  and  dwindles  away.  In  most 
mammals  no  trace  of  it  can  be  found  after  the  fourth  month  of  utero- 
gestation ;  in  some,  including  the  human  female,  it  is  said  to  exist  as  a 
minute  vesicle  at  the  placental  end  of  the  umbilical  cord  at  the  full 
period  of  pregnancy.  The  umbilical  vesicle  is  filled  with  a  yellowish 
fluid,  containing  many  oil  and  fat  globules,  similar  to  the  yelk  of  an 
egg. 

The  Allantois. — Somewhere  about  the  twentieth  day  after  concep- 
tion a  small  vesicle  is  formed  toward  the  caudal  extremity  of  the 
foetus,  which  is  called  the  allantois.  This  membrane  in  mammals  is 
important,  as  it  forms  the  greater  part  of  the  foetal  placenta,  a  small 
portion  of  it  remaining  inside  the  body  permanently  as  the  bladder. 
It  begins  as  a  diverticulum  from  the  lower  part  of  the  intestinal  canal, 
and  is  hence  formed  externally  by  the  splanchno-pleural  layer  of  the 
mesoblast,  whilst  internally  it  is  lined  by  the  hypoblast.  It  is  at  first 
spherical,  but  it  rapidly  develops  and  becomes  pyriform  in  shape, 
while  by  a  process  of  constriction,  similar  to  that  which  occurs  in  the 
vitellus  to  form  the  umbilical  vesicle,  it  becomes  divided  into  two 
parts,  communicating  with  each  other,  the  smaller  of  them  being 
eventually  developed  into  the  urinary  bladder.  The  larger  portion, 
leaving  the  abdominal  cavity  along  with  the  vitelline  duct,  rapidly 
grows  until  it  conies  into  contact  with  the  most  external  ovular  mem- 
brane, the  chorion,  over  the  inner  surface  of  which  it  spreads.  This 
part  consists  chiefly  of  mesoblastic  tissue,  the  hypoblast  only  passing 
to  the  end  of  the  stalk  of  the  allantois,  and  not  following  the  mesoblast 
as  it  spreads  over  the  inner  surface  of  the  chorion.  The  area  of  the 
chorion  over  which  the  allantois  spreads  varies  in  different  animals ; 
in  man  it  spreads  over  the  entire  surface,  but  in  the  rabbit  it  only 
occupies  one-third  of  the  chorion,  the  remaining  two-thirds  being 
occupied  by  the  yelk  sac.  This  varying  distribution  of  the  allantois 
helps  to  differentiate  the  placentation  of  man  and  the  apes  from  that 
of  rodents.  In  the  mesoblastic  tissue  of  the  allantois,  vessels  soon 
develop ;  namely,  the  two  umbilical  arteries,  derived  from  the  abdom- 
inal aorta,  and  two  umbilical  veins,  one  of  which  subsequently  dis- 
appears ;  these,  along  with  the  vitelline  duct  and  the  pedicle  of  the 
allantois,  form  the  umbilical  cord.  The  main  and  very  important 
function  of  the  allautois,  therefore,  is  to  carry  the  foetal  vessels  up  to 
the  inner  surface  of  the  sub-zonal  membrane.  Besides  this  purpose, 
the  allantois,  at  a  very  early  period,  may  receive  the  excretions  of  the 
foetus,  and  serve  as  an  excrementitious  organ.  According  to  Cazeaux, 
scarcely  a  trace  of  the  allantois  can  be  seen  a  few  days  after  its  forma- 
tion. Its  lower  part  or  pedicle,  however,  long  remains  distinct,  and 
forms  part  of  the  umbilical  cord ;  and  traces  of  it  may  be  found  even 
in  adult  life  in  the  form  of  the  urachus,  which  is  really  the  dwindled 


CONCEPTION    AND    GENERATION. 


Ill 


pedicle,  and  forms  one  of  the  ligaments  of  the  bladder.  The  cavity 
of  the  allantois  in  the  human  species  is  confined  chiefly  to  that  part 
which  lies  within  the  body  of  the  foetus  ;  it  is  seldom  persistent  further 
than  the  stalk  of  the  allantois. 


FIG.  59. 


Five  diagrammatic  figures  illustrating  the  formation  of  the  foetal  membranes  of  a  mammal.  In 
1, 2,  3,  4,  the  embryo  is  represented  in  longitudinal  section.  1.  Ovum  with  zona  pellucida,  blasto- 
dermic  vesicle,  and  embryonic  area ;  2.  Ovum  with  commencing  formation  of  umbilical  vesicle 
and  amnion ;  3.  Ovum  with  amnion  about  to  cease,  and  commencing  allantois  ;  4.  Ovum  with 
V'llous  sub-zonal  membrane,  larger  allantois,  and  mouth  and  anus  ;  5.  Ovum  in  which  the  meso- 
blastof  the  allantois  has  extended  round  the  inner  surface  of  the  sub- zonal  membrane  and  united 
with  it  to  form  the  chorion.  The  cavity  of  the  allantois  is  aborted.  This  figure  is  a  diagram  of  an 
early  human  ovum.  d.  zona  radiata  ;  d'  and  sz.  processes  of  /ona ;  sh.  sub-zonal  membrane,  outer 
fold  of  amnion,  false  amnion ;  ch.  chorion ;  chz.  chorionic  villi  ;  am.  amnion  ;  ks.  head  fold  of 
amnion  ;  ss.  tail  fold  of  amnion  ;  a.  epiblast  of  embryo  ;  a'  epiblast  of  non-embryonic  part  of  the 
blastodermic  vesicle :  m.  embryonic  mesoblast ;  m'.  non-embryonic  mesoblast ;  df.  area  vasculosa ; 
st.  sinus  terminalis :  dd.  embryonic  hypoblast ;  i.  non-embryonic  hypoblast ;  kh.  cavity  of  blasto- 
dermic vesicle,  the  greater  part  of  which  becomes  the  cavity  of  umbilical  vesicle  ds. ;  dg.  stalk  of 
umbilical  vesicle ;  al.  allantois ;  e.  embryo ;  r.  space  between  chorion  and  amnion  containing 
albuminous  fluid  ;  vl.  ventral  body  wall ;  hh.  pericardial  cavity.  (After  KOLLIKER.) 


112  PREGNANCY. 

Between  the  chorion  and  aranion  is  often  found  an  albuminous  fluid, 
with  minute  filamentous  processes  traversing  it,  called  by  Yelpeau  the 
corps  reticule,  which  is  not  met  with  until  the  allantois  comes  into 
contact  with  the  chorion,  and  which  seems  to  be  formed  out  of  the 
tissues  of  that  vesicle.  It  is  analogous  to  the  so-called  AVharton's 
jelly  found  in  the  umbilical  cord.  "When  first  formed  it  is  highly 
vascular,  but  the  vessels  entirely  disappear  after  the  placenta  is  formed, 
and  the  remainder  of  the  chorionic  villi  atrophy.  Sometimes  it  exists 
in  considerable  quantities,  and,  should  the  chorion  rupture  at  the  end 
of  pregnancy,  it  may  escape  and  give  rise  to  an  erroneous  impression 
that  the  liquor  anmii  has  been  discharged.  (Fig.  59.) 

Before  proceeding  to  consider  the  foetal  envelopes  more  at  length,  it 
may  be  useful  to  recapitulate  the  structures  already  alluded  to  as  form- 
ing the  ovum.  In  this  we  find  : 

1.  The  embryo  itself. 

2.  A  fluid,  the  liquor  amnii,  in  which  it  floats. 

3.  The  amnion,  a  purely  foetal  membrane  surrounding  the  embryo, 
and  containing  the  liquor  amnii. 

4.  The  umbilical  vesicle,  containing  the  greater  portion  of  the  yelk, 
serving  as  a  source  of  nutrition  to  the  early  embryo  through  the  vitel- 
line  duct,  and  on  which  ramify  the  omphalo-mesenteric  vessels. 

5.  The  allantois,  a  vesicle  proceeding  from  the  caudal  extremity  of 
the  embry®,  spreading  itself  over  the  interior  of  the  ovum,  and  serving 
as  a  channel  of  vascular  communication  between  the  chorion  and  the 
foetus,  through  the  umbilical  vessels. 

6.  An  interspace  between  the  outer  layer  of  the  ovum  and  the 
amnion,  in  which  is  contained  the  umbilical  vesicle  and  allantois,  and 
the  corps  reticule"  of  Velpeau. 

7.  The  outer  layer  of  the  ovum,  along  with  the  sub-zonal  membrane, 
forming  the  chorion  and  foetal  placenta. 

The  amnion  is  the  most  internal  of  the  two  membranes  surround- 
ing the  foetus ;  its  origin  at  an  early  period  of  foetal  life  has  already 
been  described.  It  is  a  perfectly  smooth,  transparent,  but  tough  mem- 
brane, continuous  with  the  integument  of  the  foetus  at  the  insertion  of 
the  umbilical  cord,  round  which  it  forms  a  sheath.  Soon  after  it  is 
formed  it  becomes  distended  with  a  fluid,  the  liquor  amnii,  in  which 
the  foetus  is  suspended  and  floats.  This  fluid  increases  gradually  in 
quantity,  distending  the  amnion  as  it  does  so,  until  this  is  brought  into 
close  proximity  to  the  inner  surface  of  the  choriou,  from  which  it  was 
at  first  separated  by  a  considerable  interspace. 

The  internal  surface  of  the  amnion  is  smooth  and  glistening,  and 
on  microscopic  examination  it  is  found  to  consist  of  a  layer  of  flattened 
cells,  each  containing  a  large  nucleus.  These  rest  on  a  stratum  of 
fibrous  tissue,  which  gives  to  the  membi-ane  its  toughness,  and  by 
which  it  is  attached  to  a  layer  of  gelatinous  tissue  Avhieh  separates  it 
from  the  inner  surface  of  the  chorion.  This  fibrous  layer  contains 
muscular  fibres  which  give  to  the  amnion  its  contractility.  It  is 
entirely  destitute  of  vessels,  nerves,  and  lymphatics.  The  quantity 
of  the  liquor  amnii  varies  much  at  different  periods  of  pregnancy. 
In  the  early  mouths  it  is  relatively  greater  in  amount  than  the  f<etus, 


CONCEPTION    AND    GENERATION.  113 

which  it  outweighs.  As  pregnancy  advances,  the  weight  of  the  foetus 
becomes  four  or  five  times  greater  than  that  of  the  liquor  amnii, 
although  the  actual  quantity  of  fluid  increases  during  the  whole 
period  of  gestation.  The  amount  of  fluid  varies  much  in  different 
pregnancies.  Sometimes  there  is  comparatively  little ;  while  at  others 
the  quantity  is  immense,  reaching  several  pounds  in  weight,  greatly 
distending  the  uterus,  and  thus,  it  may  be,  producing  difficulty  in 
labor. 

At  first  the  liquid  is  clear  and  limpid.  As  pregnancy  advances  it 
becomes  more  turbid  and  dense,  from  the  admixture  of  epithelial 
debris  derived  from  the  cutaneous  surface  of  the  foetus.  In  some 
cases,  without  actual  disease,  it  may  .be  dark-green  in  color,  and  thick 
and  tenacious  in  consistency.  It  has  a  peculiar  heavy  odor,  and  it 
consists  chemically  of  water  containing  albumin,  some  urea,  and 
various  salts,  principally  phosphates  and  chlorides. 

The  source  of  the  liquor  amnii  has  been  much  disputed.  Some 
maintain  that  it  is  derived  chiefly  from  the  foetus,  a  view  sufficiently 
disproved  by  the  fact  that  the  liquor  amnii  continues  to  increase  in 
amount  after  the  death  of  the  foetus.  Burdach  believed  that  it  is 
secreted  by  the  internal  surface  of  the  uterus,  and  arrives  in  the 
cavity  of  the  amnion  by  transudation  through  the  membrane.  Priest- 
ley thinks — and  this  seems  the  most  probable  hypothesis — that  it  is 
secreted  by  the  epithelial  cells  lining  the  membrane,  which  become 
distended  with  fluid,  burst,  and  pour  their  contents  into  the  amniotic 
cavity.  Gusserow,1  whose  view  is  adopted  by  Spiegelberg,  maintains 
that  in  the  latter  months  of  pregnancy  the  quantity  of  the  liquor 
amnii  is  largely  increased  by  the  foetal  urine  which  is  passed  into  the 
amniotic  sac.  (See  page  137.) 

The  most  obvious  use  of  the  liquor  amnii  is  to  afford  a  fluid  medium 
in  which  the  foetus  floats,  and  so  is  protected  from  the  shocks  and  jars 
to  which  it  would  otherwise  be  subjected,  and  from  undue  pressure 
upon  the  uterine  walls.  By  distending  the  uterus  it  saves  it  from 
injury,  which  the  movements  of  the  foetus  might  otherwise  inflict,  and 
the  foetus  is  thus  also  enabled  to  change  its  position  freely.  The 
facility  with  which  version  by  external  manipulation  can  be  effected 
depends  entirely  on  the  mobility  of  the  foetus  in  the  fluid  which  sur- 
rounds it.  Some  have  also  supposed  that  it  prevents  the  foetus,  in 
the  early  months  of  pregnancy,  from  forming  adhesions  to  the  amnion. 
In  labor,  it  is  of  great  service,  by  lubricating  the  passages,  but  chiefly 
by  forming,  with  the  membranes,  a  fluid  wedge,  which  dilates  the 
circle  of  the  os  uteri. 

In  a  few  rare  cases  there  is  a  certain  amount  of  limpid  fluid  between 
the  chorion  and  the  amnion,  separating  the  two  membranes.  This  is 
apparently  only  a  more  than  usually  fluid  condition  of  the  gelatinous 
tissue  which  naturally  exists  between  the  chorion  and  amnion.  Occa- 
sionally, after  the  bag  of  membranes  is  felt  in  labor,  the  chorion  alone 
ruptures,  and  the  spurious  liquor  amnii  is  discharged,  giving  the 
attendant  the  impression  that  the  membranes  have  been  ruptured. 

i  Arch.  f.  Gyniik.,  Bd.  iii.  S.  241,  "Zur  Lehre  vom  Stoffwechsel  des  Foetus." 

8 


114  PREGNANCY. 

The  chorion  is  the  more  external  of  the  truly  foetal  membranes, 
although  external  to  it  is  the  decidua,  having  a  strictly  maternal 
origin.  It  is  a  perfectly  closed  sac,  its  external  surface,  in  contact 
with  the  decidua,  being  rough  and  shaggy  from  the  development  of 
villi  (Fig.  56),  its  internal  smooth  and  shining.  As  the  ovum  passes 
along  the  Fallopian  tube  it  receives,  as  we  have  seen,  an  albuminous 
coating,  and  this,  with  the  zona  pellucida,  is  developed  into  a  tem- 
porary structure,  the  primitive  chorion.  This  primitive  chorion,  as 
the  amnion  develops,  is  reinforced  by  the  layer  of  epiblast  covering 
the  umbilical  vesicle  externally  which  separates  it  from  the  subjacent 
mesoblast  and  hypoblast,  and  together  with  the  epiblastic  layer  of  the 
false  amnion,  with  which  it  is  continuous,  passes  to  the  primitive 
chorion,  either  combining  with  this,  or  by  pressure  causing  its  absorp- 
tion and  disappearance. 

The  membrane  thus  formed  is  called  by  Turner  the  sub-zonal  mem- 
brane, and  by  Von  Baer  the  serous  envelope.  From  it  are  developed 
villi  of  cellular  structure,  which  at  first  extend  as  a  ring  round  the 
ovum,  but  eventually  cover  the  whole  of  its  surface.  These  villi  are 
finger-like  projections  from  the  surface  of  the  ovum,  which  are  re- 
ceived into  corresponding  depressions  in  the  decidua,  with  which  they 
soon  become  so  firmly  united  that  they  cannot  be  separated  without 
laceration. 

As  the  allantois  develops,  its  mesoblastic  layer  grows  into  the  space 
between  the  embryo  and  the  sub-zonal  membrane,  and,  in  the  human 
subject,  spreads  over  the  whole  of  its  inner  surface,  combining  with  it 
to  form  a  new  membrane,  the  true  or  complete  chorion.  Each  villus 
now  receives  a  separate  artery  and  vein,  the  former  having  a  branch 
to  each  of  the  subdivisions  into  which  the  villus  divides*  These 
vessels  are  encased  in  a  fine  connective-tissue  sheath  from  the  allantois, 
which  enters  the  villus  along  with  them  and  forms  a  lining  to  it 
described  by  some  as  the  endochorion;  the  external  epithelial  mem- 
brane of  the  villus,  derived  from  the  epiblast  layer  of  the  blastodermic 
membrane,  being  called  the  exochorion.  The  artery  and  vein  lie  side 
by  side  in  the  centre  of  the  villus,  and  anastomose  at  its  extremity ; 
each  villus  thus  having  a  separate  circulation. 

As  soon  as  the  union  of  the  allautois  with  the  chorion  has  been 
effected,  the  villi  grow  very  rapidly,  give  off  branches,  which,  in  their 
turn,  give  off  secondary  branches,  and  so  form  root-like  processes  of 
great  complexity.  In  the  early  months  of  gestation  they  exist  equally 
over  the  whole  surface  of  the  ovum.  As  pregnancy  advances,  how- 
ever, those  which  are  in  contact  with  the  decidua  reflex'a  shrivel  up, 
and  by  the  end  of  the  second  month  cease  to  be  vascular,  being  no 
longer  required  for  the  nutrition  of  the  ovum.  The  chorion  and 
decidua  thus  come  into  close  contact,  being  united  together  by  fibrous 
shreds,  which  on  microscopic  examination  are  found  to  consist  of 
atrophied  villi.  The  union  between  the  chorion  and  the  decidua  re- 
flexa  as  pregnancy  advances  becomes  so  complete  that  their  line  of 
junction  cannot  be  ascertained,  and  they  together  with  the  decidua 
vera  form  one  membrane,  which  on  its  inner  surface  is  only  separated 
from  the  amnion,  which  has  spread  over  it,  by  a  fine  layer  of  gelatinous 


CONCEPTION    AND    GENERATION.  115 

tissue.  The  portion  of  the  chorion  which  is  in  relationship  to  the 
decidua  refiexa  is  known  as  the  chorion  Iceve,  whilst  that  in  contact 
with  the  decidua  serotina  receives  the  name  of  the  chorion  frondosum, 
and  in  this  portion  the  villi,  instead  of  dwindling  away,  increase 
greatly  in  size,  and  eventually  develop  into  the  organ  by  which  the 
foetus  is  nourished — the  placenta. 

Form  of  the  Placenta. — This  important  organ  serves  the  purpose 
of  supplying  nutriment  to,  and  aerating  the  blood  of,  the  fetus,  and  on 
its  integrity  the  existence  of  the  foetus  depends.  It  is  met  with  in  all 
mammals,  but  is  very  different  in  form  and  arrangement  in  different 
classes.  Thus,  in  the  sow,  mare,  and  in  the  cetacea,  it  is  diffused  over 
the  whole  interior  of  the  uterus ;  in  the  ruminants,  it  is  divided  into  a 
number  of  separate  small  masses,  scattered  here  and  there  over  the 
uterine  walls;  while  in  the  carnivora  and  elephant  it  forms  a  zone  or 
belt  round  the  uterine  cavity.  In  the  human  race,  as  well  as  in 
rodentia,  insectivora,  etc.,  the  placenta  is  in  the  form  of  a  circular 
mass,  attached  generally  to  some  part  of  the  uterus  near  the  orifice  of 
one  Fallopian  tube ;  but  it  may  be  situated  anywhere  in  the  uterine 
cavity,  even  over  the  internal  os  uteri.  The  form  of  placentation  in 
man  and  the  apes  is  known  as  the  meta-discoidal,  whilst  in  rodentia 
and  insectivora  the  placentation  is  discoidal.  The  meta-discoidal 
placentation  is  placed  ventrally  with  regard  to  the  embryo,  and  the 
allantois  extends  over  the  whole  of  the  sub-zonal  membrane,  whilst  in 
the  discoidal  variety  the  placenta  is  placed  dorsally,  and  the  allantois 
only  extends  over  a  portion  of  the  sub-zonal  membrane,  to  the  re- 
mainder of  wrhich  the  yelk  sac  is  applied.  As  it  is  expelled  after 
delivery  with  the  foetal  membranes  attached  to  it,  and  as  the  aperture 
in  these  corresponds  to  the  os  uteri,  we  can  generally  determine  pretty 
accurately  the  situation  in  which  the  placenta  was  placed  by  examining 
them  after  expulsion.  The  maternal  surface  of  the  placenta  is  some- 
what convex,  the  foetal  concave.  Its  size  varies  greatly  in  different 
cases,  and  it  is  usually  largest  when  the  child  is  big,  but  not  necessarily 
so.  Its  average  diameter  is  from  six  to  eight  inches,  its  weight  from 
eighteen  to  twenty-four  ounces,  but  in  exceptional  cases  it.  has  been 
found  to  weigh  several  pounds.  Abnormalities  of  form  are  not  very 
-rare.  Thus,  the  placenta  has  been  found  to  be  divided  into  distinct 
parts,  a  form  said  by  Professor  Turner  to  be  normal  in  certain  genera 
of  monkeys ;  or  smaller  supplementary  placentae  (placentce  succenturice) 
may  exist  round  a  central  mass.  These  variations  of  shape  are  only 
of  importance  in  consequence  of  a  risk  of  part  of  the  detached  placenta 
being  left  in  the  uterus  after  delivery,  and  giving  rise  to  septicaemia 
or  secondary  hemorrhage. 

The  foetal  membranes  cover  the  whole  foetal  surface  of  the  placenta, 
being  reflected  from  its  edges  so  as  to  line  the  uterine  cavity,  and  being 
expelled  with  it  after  delivery.  They  also  leave  it  at  the  insertion  of 
the  cord,  to  which  they  form  a  sheath.  The  cord  is  generally  attached 
near  the  centre  of  the  placenta,  and  from  its  insertion  the  umbilical 
vessels  may  be  seen  dividing  and  radiating  over  the  whole  foetal 
surface. 

The  maternal  surface  is  rough  and  divided  by  numerous  sulci,  which 


116  PREGNANCY. 

are  best  seen  if  the  placenta  is  rendered  convex,  so  as  to  resemble  its 
condition  when  attached  to  the  uterus.  A  careful  examination  shows 
that  a  delicate  membrane  covers  the  entire  maternal  surface,  unites  the 
sulci  together,  and  dips  down  between  them.  This  is,  in  fact,  the 
cellular  layer  of  the  decidua  serotina,  which  is  separated  and  expelled 
with  the  placenta,  the  deeper  layer  remaining  attached  to  the  uterus. 
Numerous  small  openings  may  be  seen  on  the  surface,  which  are  the 
apertures  of  the  veins  torn  off  from  the  uterus,  as  also  those  of  some 
arteries,  which,  after  taking  several  sharp  turns,  open  suddenly  into 
the  substance  of  the  organ. 

As  regards  the  minute  structure  of  the  placenta,  it  is  certain  that  it 
consists  essentially  of  two  distinct  portions — one  foetal,  consisting  of 


Placenta!  villus,  greatly  magnified.    1,  2.  Placental  vessels,  forming  terminal  loops.    3.  Chorion 
tissue,  forming  external  walls  of  villus.    4.  Tissue  surrounding  vessels.    (After  JOULIN.) 

the  greatly  hypertrophied  chorion  villi,  with  their  contained  vessels, 
which  carry  the  foetal  blood  so  as  to  bring  it  into  intimate  relation  with 
the  maternal  blood,  and  thus  admit  of  the  necessary  changes  occurring 
in  it  connected  with  the  nutrition  of  the  foetus ;  and  the  other  maternal, 
formed  out  of  the  decidua  serotina  and  the  maternal  bloodvessels. 
These  two  portions  are  in  the  human  female  so  intimately  blended 
as  to  form  the  single  deciduous  organ  which  is  thrown  off  after 
delivery.  These  main  facts  are  admitted  by  all,  but  considerable 
differences  of  opinion  still  exist  among  anatomists  as  to  the  precise 
arrangement  of  these  parts.  In  the  following  sketch  of  the  subject  I 
shall  describe  the  views  most  generally  entertained,  merely  briefly 
indicating  the  points  which  are  contested  by  various  authorities. 


CONCEPTION    AND    GENERATION.  117 

The  foetal  portion  of  the  placenta  consists  essentially  of  the  ultimate 
ramifications  of  the  chorion  villi,  which  may  be  seen  on  microscopic 
examination  in  the  form  of  club-shaped  digitations,  which  are  given 
off  at  every  possible  angle  from  the  stem  of  a  parent  trunk,  just  like 
the  branches  of  a  plant.  Within  the  transparent  walls  of  the  villi  the 
capillary  tubes  of  the  contained  vessels  may  be  seen  lying,  distended 
with  blood,  and  presenting  an  appearance  not  unlike  loops  of  small 
intestine.  The  capillaries  are  the  terminal  ramifications  of  the 
umbilical  arteries  and  veins,  which,  after  reaching  the  site  of  the 
placenta,  divide  and  subdivide  until  they  at  last  form  an  immense 
number  of  minute  capillary  vessels,  with  their  convexities  looking 
toward  the  maternal  portion  of  the  placenta,  each  terminal  loop  being 
contained  in  one  of  the  digitations  of  the  chorion  villi.  Each  arterial 
twig  is  accompanied  by  a  corresponding  venous  branch,  which  unites 
with  it  to  form  the  terminal  arch  or  loop  (Fig.  60).  The  foetal  blood 

FIG.  61. 


o.  Terminal  villus  of  foetal  tuft,  minutely  injected,    b.  Its  nucleated  non-vascular  sheath. 

(After  FAERE.) 

is  carried  through  these  arterial  twigs  to  the  villi,  where  it  comes  into 
intimate  contact  with  the  maternal  blood,  in  consequence  of  the 
anatomical  arrangements  presently  to  be  described ;  but  the  two  do  not 
directly  mix,  as  the  older  physiologists  believed,  for  none  of  the 
maternal  blood  escapes  when  the  umbilical  cord  is  cut,  nor  can  the 
minutest  injections  through  the  foetal  vessels  be  made  to  pass  into  the 
maternal  vascular  system,  or  vice  versa.  In  addition  to  the  looped 
terminations  of  the  umbilical  vessels,  Farre  and  Schroeder  van  der 
Kolk  have  described  another  set  of  capillary  vessels  in  connection  with 
each  villus  (Fig.  61).  This  consists  of  a  very  fine  network  covering 
cadi  villus,  and  very  different  in  appearance  from  the  convoluted 
vessels  lying  in  its  interior,  which  are  the  only  ones  which  have  been 
usually  described.  Dr.  Farre  believes  that  these  vessels  only  exist  in 
the  early  months  of  pregnancy,  and  that  they  disappear  as  pregnancy 


118 


PREGNANCY. 


advances.  Priestley1  suggests  that  they  may  not  be  vessels  at  all,  but 
lymphatics,  which  may  possibly  absorb  nutrient  material  from  the 
mother's  blood,  and  throw  it  into  the  foetal  vascular  system.  The 
existence  of  lymphatics,  or  of  nerves,  in  the  placenta,  however,  has 
never  been  demonstrated,  and  they  are  believed  not  to  exist. 

As  generally  described,  the  maternal  portion  of  the  placenta  consists 
of  large  cavities,  or  of  a  single  large  cavity,  which  contain  the  maternal 
blood,  and  into  which  the  villi  of  the  chorion  penetrate  (Fig.  62). 
Into  this  maternal  part  of  the  viscus,  the  curling  arteries  of  the  uterus 
pour  their  blood,  which  is  collected  from  it  by  the  uterine  sinuses. 

FIG.  62. 


Diagram  representing-  a  vertical  section  of  the  placenta,    a,  a.  Chorion.    b,  b.  Decidua. 
c,  c,  c,  c.  Orifices  of  uterine  sinuses.    (After  DALTON.) 

The  villi  of  the  chorion,  therefore,  are  suspended  in  a  sac  filled  with 
maternal  blood,  which  penetrates  freely  between  them,  and  with  which 
they  are  brought  into  very  intimate  contact.  Dr.  John  Reid  believed 
that  only  the  delicate  internal  lining  of  the  maternal  vessels  entered 
the  substance  of  the  placenta,  to  form  the  sac  just  spoken  of.  Into 
this  the  villi  project,  pushing  before  them  the  membrane  forming  the 
limiting  wall  of  the  placental  sinuses,  each  of  them  in  this  way  re- 
ceiving an  investment,  just  as  the  fingers  of  a  hand  are  covered  by  a 
glove  (Fig.  63). 

Schroeder  van  der  Kolk  and  Goodsir  (Fig.  64)  were  of  opinion 
that  not  only  were  the  maternal  bloodvessels  continued  into  the  sub- 
stance of  the  placenta,  but  also  the  processes  of  the  decidua,  which 
accompanied  the  vessels  and  were  prolonged  over  each  villus,  so  as  to 
separate  it  from  the  lining  membrane  of  the  maternal  sinuses.  Each 
villus  would  thus  be  covered  by  two  layers  of  fine  tissue,  one  from  the 
internal  lining  membrane  of  the  maternal  bloodvessels,  the  other  from 
the  epithelial  cells  of  the  decidua. 

1  The  Gravid  Uterus,  p.  52. 


CONCEPTION    AND    GENERATION. 


119 


Turner,  whose  valuable  researches  on  the  comparative  anatomy  of 
the  placenta  have  thrown  much  light  on  its  structure,  points  out  that 
the  placenta  of  all  animals  are  formed  on  the  same  fundamental  type,1 
in  which  the  foetal  portion  consists  of  a  smooth,  plane-surfaced  vas- 
cular membrane,  covered  with  pavement  epithelium,  which  is  brought 
into  contact  with  the  maternal  portion,  consisting  of  a  smooth,  plane- 
surfaced  vascular  membrane  covered  with  columnar  epithelium.  The 
foetal  capillaries  are  separated  from  the  maternal  capillaries  only  by 
two  opposed  layers  of  epithelium.  In  various  animals  the  placentae 
are  more  or  less  specialized  from  the  generalized  form,  in  some  to  a 
much  greater  extent  than  others.  In  tke  human  placenta  the  maternal 


FIG.  63. 


FIG.  64. 


Diagram  illustrating  the  mode  in  which  a 
placental  villus  derives  a  covering  from  the 
vascular  system  of  the  mother,  a.  Villus 
having  three  terminal  digitations  projecting 
into  b.  Cavity  of  the  mother's  vessel,  c.  Dotted 
lines  representing  coat  of  vessel.  (After 
PRIESTLEY.) 


The  extremity  of  a  placental  villus.  a  Ex- 
ternal membrane  of  villus  (the  lining  mem- 
brane of  vascular  system  of  Weber).  6.  Ex- 
ternal cells  of  villus  derived  from  decidua. 
c,  c.  Nuclei  of  ditto,  d.  The  space  between 
the  maternal  and  .ftetal  portions  of  villus. 
e.  Its  internal  membrane.  /.  Its  internal 
cells,  g.  The  loop  of  umbilical  vessels. 
(After  QOODSIK.) 


vessels  have  lost  their  normal  cylindrical  form,  and  are  dilated  into 
a  system  of  freely  intercommunicating  placental  sinuses,  which  are,  in 
fact,  maternal  capillaries  enormously  enlarged,  with  their  walls  so 
expanded  and  thinned  out  that  they  cannot  be  recognized  as  a  distinct 
layer  limiting  the  sinus.  Each  foetal  chorion  villus  projecting  into 
these  sinuses  is  covered  with  a  layer  of  cells  distinct  from  those  of  the 
epithelial  layer  of  the  villus,  and  readily  stripped  from  it.  These  are 
maternal  in  their  origin,  and  are  derived  from  the  decidua,  which 
sends  prolongations  of  its  tissue  into  the  placenta.  These  cells,  he 
believes,  form  a  secreting  epithelium  which  separates  from  the  maternal 
blood  a  secretion,  for  the  nourishment  of  the  foetus,  which  is,  in  its 
turn,  absorbed  by  the  villi  of  the  chorion. 

A  view  not  very  dissimilar  to  this  has  been  advanced  by  Professor 
Ercolani,  of  Bologna,  who  maintains  that  the  maternal  portion  of  the 
placenta  is  a  new  formation,  strictly  glandular,  and  not  vascular,  in 
its  structure.  It  is  formed,  he  thinks,  by  the  submucous  connective 
tissue  of  the  decidua  serotina,  and  it  dips  down  into  the  placenta  and 


1  Introduction  to  Human  Anatomy,  Part  2,  and  Journ.  of  Anat.  and  Physiology,  1877,  vol.  xi. 
p.  33. 


120  PREGNANCY. 

forms  a  sheath  to  each  of  the  chorion  villi,  which  it  separates  from 
the  maternal  blood.  This  new  glandular  structure  he  describes  as 
secreting  a  fluid,  termed  the  "  uterine  milk,"  which  is  absorbed  by  the 
villi  of  the  chorion,  just  as  the  mother's  milk  is  absorbed  by  the  villi 
of  the  intestines,  and  it  is  with  this  fluid  alone  that  the  chorion  villi 
are  in  direct  contact.  The  sheath  thus  formed  to  each  villus  is 
doubtless  analogous  to  the  layer  of  cells  which  Goodsir  described  as 
encasing  each  villus,  but  is  attributed  to  a  new  structure  formed  after 
conception. 

The  existence  of  the  maternal  sinus  system  in  the  placenta  is  alto- 
gether denied  by  anatomists  o*f  eminence  whose  views  are  worthy  of 
careful  consideration.  Prominent  amongst  these  is  Braxton  Hicks,1 
who  has  written  an  elaborate  paper  on  the  subject.  He  holds  that 
there  is  no  evidence  to  prove  that  the  maternal  blood  is  poured  out 
into  a  cavity  in  which  the  chorion  villi  float,  and  he  believes  that  the 
curling  arteries,  instead  of  entering  the  so-called  maternal  portion  of 
the  placenta,  terminate  in  the  decidua  serotina.  The  hypertrophied 
choriou  villi  at  the  site  of  the  placenta  are  firmly  attached  to  the 
decidual  surface,  into  which  their  tips  are  imbedded.  The  line  of 
junction  between  the  decidua  reflexa  and  serotina  forms  a  circum- 
ferential margin  to,  and  limits,  the  placenta.  The  arrangement  of 
the  fetal  portion  of  the  placenta  on  this  view  is  very  similar  to  that 
generally  described,  but  the  villi  are  not  surrounded  by  maternal  blood 
at  all,  and  nothing  exists  between  them,  unless  it  be  a  small  quantity 
of  serous  fluid.  The  change  in  the  foetal  blood  is  effected  by  endos- 
mosis,  and  Hicks  suggests  that  the  follicles  of  the  decidua  may  secrete 
a  fluid,  which  is  poured  into  the  intervillous  spaces  for  absorption  by 
the  villi. 

Functions  of  the  Placenta. — It  will  thus  be  seen  that  anatomists 
of  repute  are  still  undecided  as  to  important  points  in  the  minute 
anatomy  of  the  placenta,  which  further  investigation  will  doubtless 
clear  up.  The  main  functions  of  the  organ  are,  however,  sufficiently 
clear.  During  the  entire  period  of  its  existence  it  fills  the  important 
office  of  both  stomach  and  lungs  to  the  fetus.  Whatever  view  of  the 
arrangement  of  the  maternal  bloodvessels  be  taken,  it  is  certain  that 
the  fetal  blood  is  propelled  by  the  pulsations  of  the  fetal  heart  into 
the  numberless  villi  of  the  chorion,  where  it  is  brought  into  very 
intimate  relation  with  the  mother's  blood,  gives  off  its  carbonic  acid, 
absorbs  oxygen,  and  passes  back  to  the  fetus,  through  the  umbilical 
vein,  in  a  fit  state  for  circulation.  The  mode  of  respiration,  therefore, 
in  the  foetus  is  analogous  to  that  in  fishes,  the  chorion  villi  represent- 
ing the  gills,  the  maternal  blood  the  water  in  which  they  float.  Nutri- 
tion is  also  effected  in  the  organ,  and,  by  absorption  through  the 
chorion  villi,  the  pabulum  for  the  nourishment  of  the  fetus  is  taken 
up.  It  also  probably  serves  as  an  emunctory  for  the  products  of 
excretion  in  the  fetus.  Picard  found  that  the  blood  in  the  placenta 
contained  an  appreciably  larger  quantity  of  urea  than  that  in  other 
parts  of  the  body,  this  urea  probably  being  derived  from  the  fetus. 

Obst.  Trans.,  1873,  vol.  xiv.  p.  149. 


CONCEPTION    AND    GENERATION.  121 

Claude  Bernard  also  attributed  to  it  a  glycogenic  function/  supposing 
it  to  take  the  place  of  the  foetal  liver  until  that  organ  was  sufficiently 
developed. 

Finally,  we  find  that  the  temporary  character  of  the  placenta  is 
indicated  by  certain  degenerative  changes,  which  take  place  in  it 
previous  to  expulsion.  These  consist  chiefly  in  the  deposit  of  cal- 
careous patches  on  its  uterine  surface,  and  in  fatty  degeneration  of  the 
villi  and  of  the  decidual  layer  between  the  placenta  and  the  uterus. 
If  this  degeneration  be  carried  to  excess,  as  is  not  imfrequently  the 
case,  the  foetus  may  perish  from  want  of  a  sufficient  number  of 
healthy  villi  through  which  its  respiration  and  -nutrition  may  be 
effected. 

The  umbilical  cord  is  the  channel  of  communication  between  the 
foetus  and  placenta,  being  attached  to  the  former  at  the  umbilicus,  to 
the  latter  generally  near  its  centre,  but  sometimes,  as  in  the  battledore 
placenta,  at  its  edge.  It  varies  much  in  length,  measuring  on  an 
average  from  eighteen  to  twenty-four  inches,  but  in  exceptional  cases 
being  found  as  long  as  fifty  or  sixty,  and  as  short  as  five  or  six 
inches. 

When  fully  formed  it  consists  of  an  external  membranous  layer 
formed  of  the  amnion,  two  umbilical  arteries,  one  umbilical  vein,  and 
a  considerable  quantity  of  a  transparent  gelatinous  substance  surround- 
ing the  vessels,  called  Wharton's  jelly,  which  is  contained  in  a  fine 
network  of  fibres,  and  is  formed  from  the  somato-pleural  layer  of  the 
mesoblast  in  the  cord.  At  an  early  period  of  pregnancy,  in  addition 
to  these  structures,  the  cord  contains  the  pedicle  of  the  umbilical 
vesicle,  with  the  omphalo-mesenteric  vessels  ramifying  on  it,  and 
two  umbilical  veins,  one  of  which  soon  atrophies  and  disappears.  No 
nerves  or  lymphatics  have  been  satisfactorily  demonstrated  in  the 
cord,  although  such  have  been  described  as  existing.  The  vessels  of 
the  cord  are  at  first  straight  in  their  course,  but  shortly  they  become 
greatly  twisted,  the  arteries  being  external  to  the  vein,  and  in  nine 
cases  out  of  ten  the  twist  is  from  left  to  right.  Various  explanations 
have  been  given  of  this  peculiarity,  none  of  them  entirely  satisfactory. 
Tyler  Smith  attributed  it  to  the  movements  of  the  foetus  twisting  the 
cord,  its  attachment  to  the  placenta  being  a  fixed  point ;  this  would 
not,  however,  account  for  the  frequency  with  which  the  spiral  turns 
occur  in  one  direction.  Mr.  John  Simpson  attributed  it  to  the  greater 
pressure  of  the  blood  through  the  right  hypogastric  artery,  on  account 
of  that  vessel  having  a  more  direct  relation  to  the  aorta  than  the  left. 
The  umbilical  arteries  give  off  no  branches,  and  the  vein  contains  no 
valves,  nor  can  any  vasa  vasorum  be  detected  in  their  coats  after  they 
have  left  the  umbilicus.  The  umbilical  arteries  increase  in  size  after 
tKey  leave  the  cord,  to  divide  on  the  surface  of  the  placenta.  This  is 
the  only  example  in  the  body  in  which  arteries  are  larger  near  their 
terminations  than  their  origin,  and  the  object  of  this  arrangement  is 
probably  to  effect  a  retardation  of  the  current  of  the  blood  distributed 
to  the  placenta.  The  tortuous  course  of  the  vein  probably  compensates 

i  Acad.  des  Sciences,  April,  1859. 


122  PREGNANCY. 

for  the  absence  of  valves,  and  moderates  the  flow  of  blood  through 
it.1 

Distinct  knots  are  not  unfrequently  observed  in  the  cord,  but  they 
rarely  have  the  effect  of  obstructing  the  circulation  through  it.  They 
no  doubt  form  when  the  fetus  is  very  small.  They  may  sometimes 
also  be  produced  in  labor  by  the  child  being  propelled  through  a  coil 
of  the  cord  lying  circularly  around  the  os  uteri.  The  so-called  false 
knots  are  merely  accidental  nodosities  due  to  local  enlargements  of  the 
vessels. 


CHAPTEE    II. 

THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS. 

IT  is  obviously  impossible  to  attempt  anything  like  a  full  account 
of  the  development  of  the  various  foetal  structures,  or  of  their  growth 
during  intra-uterine  life.  To  do  so  would  lead  us  far  beyond  the 
scope  of  this  work,  and  would  involve  a  study  of  complex  details  only 
suitable  in  a  treatise  on  embryology.  It  is  of  importance,  however, 
that  the  practitioner  should  have  it  in  his  power  to  determine  approxi- 
mately the  age  of  the  foetus  in  abortions  or  premature  labors,  and  for 
this  purpose  it  is  necessary  to  describe  briefly  the  appearance  of  the 
foetus  at  various  stages  of  its  growth. 

1st  Month.  The  foetus  in  the  first  mouth  of  gestation  is  a  minute 
gelatinous  and  semi-transparent  mass,  of  a  grayish  color,  in  which  no 
definite  structure  can  be  made  out,  and  in  which  no  head  or  extremities 
can  be  seen.  It  is  rarely  to  be  detected  in  abortions,  being  lost  in 
surrounding  blood-clots.  In  the  few  examples  which  have  been  care- 
fully examined  it  did  not  measure  more  than  a  line  in  length.  It  is, 
however,  already  surrounded  by  the  amuiou,  and  the  pedicle  of  the 
umbilical  vesicle  can  be  traced  into  the  unclosed  abdominal  cavity. 

2d  Month.  The  embryo  becomes  more  distinctly  apparent,  and  is 
curved  on  itself,  weighing  about  sixty-two  grains,  and  measuring  six 
to  eight  lines  in  length.  The  head  and  extremities  are  distinctly  vis- 
ible— the  latter  in  the  form  of  rudimentary  projections  from  the  body. 
The  eyes  are  to  be  seen  as  small  black  spots  on  the  side  of  the  head. 
The  spinal  column  is  divided  into  separate  vertebrae.  The  indepen- 
dent circulatory  system  of  the  foetus  is  now  beginning  to  form,  the 
heart  consisting  of  only  one  ventricle  and  one  auricle,  from  the  former 
of  which  both  the  aorta  and  pulmonary  arteries  arise.  On  either  side 
of  the  vertebral  column,  reaching  from  the  heart  to  the  pelvis,  are  two 

f1  In  some  Instances  the  disproportionate  length  of  the  vein  causes  the  cord  to  assume  a  screw- 
like  form,  which  may  be  very  regular,  as  is  exhibited  to  a  remarkable  degree  by  one  in  my 
possession,  in  which  there  are  between  thirty  and  forty  turns,  involving  the  whole  funis,  which  is 
of  average  length  in  a  straight  line.— ED.] 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.          123 

large  glandular  structures,  the  corpora  Wolffiana,  which  consist  of  a 
series  of  convoluted  tubes  opening  into  an  excretory  duct,  running 
along  their  external  borders,  and  connected  below  with  the  common 
cloaca  of  the  genito-urinary  and  digestive  tracts.  They  seem  to  act  as 
secreting  glands,  and  fulfil  the  functions  of  the  kidneys  before  they 
are  formed.  Toward  the  end  of  the  second  month  they  atrophy  and 
disappear,  and  the  only  trace  of  them  in  the  foetus  at  term  is  to  be 
found  in  the  parovarium  lying  between  the  folds  of  the  broad  liga- 
ments. At  this  stage  of  development  there  are  met-  with  in  the  human 
embryo,  as  in  that  of  all  mammals,  four  transverse  fissures  opening 
into  the  pharynx,  which  are  analogous  to  the  permanent  branchiae  of 
fishes.  Their  vascular  supply  is  also  similar,  as  the  aorta  at  this  time 
gives  off  four  branches  on  each  side,  each  of  which  forms  a  branchial 
arch,  and  these  afterward  unite  to  form  the  descending  aorta.  By  the 
end  of  the  sixth  week  these,  as  well  as  the  transverse  fissures  to  which 
they  are  distributed,  disappear.  By  the  end  of  the  second  month  the 
kidneys  and  supra-renal  capsules  are  forming,  and  the  single  ventricle 
is  divided  into  two  by  the  growth  of  the  inter-ventricular  septum. 
The  umbilical  cord  is  quite  straight,  and  is  inserted  into  the  lower 
part  of  the  abdomen.  Centres  of  ossification  are  showing  themselves 
in  the  inferior  maxillary  bones  and  the  clavicle. 

3d  Month.  The  embryo  weighs  from  seventy  to  three  hundred 
grains,  and  measures  from  t\vo  and  a  half  to  three  and  a  half  inches 
in  length.  The  forearm  is  well  formed,  and  the  first  traces  of  the 
fingers  can  be  made  out.  The  head  is  large  in  proportion  to  the  rest 
of  the  body,  and  the  eyes  are  prominent ;  the  mouth  is  closed  by  the 
lips,  and  is  separated  by  them  from  the  nasal  cavity.  The  umbilical 
vesicle  and  allantois  have  disappeared,  and  the  alimentary  canal  is 
now  situated  entirely  within  the  abdominal  cavity.  The  greater 
portion  of  the  chorion  villi  have  atrophied,  and  the  placenta  is 
distinctly  formed. 

4th  Month.  The  weight  is  from  four  to  six  ounces,  and  the  length 
about  six  inches.  The  convolutions  of  the  brain  are  beginning  to 
develop.  The  sex  of  the  child  can  now  be  ascertained  on  inspection. 
Hairs  begin  to  be  formed  on  the  head.  The  muscles  are  sufficiently 
formed  to  produce  distinct  movements  of  the  limbs.  Ossification  is 
extending,  and  can  be  traced  in  the  occipital  and  frontal  bones,  and  in 
the  mastoid  processes.  The  sexual  organs  are  differentiated. 

5th  Month.  Weight  about  ten  ounces.  Length,  nine  or  ten  inches. 
Hair  is  observed  covering  the  head,  which  forms  about  one-third  of 
the  length  of  the  whole  foetus.  The  nails  are  beginning  to  form,  and 
ossification  has  commenced  in  the  ischium.  The  foetal  movements  are 
distinct,  and  in  cases  of  premature  delivery,  may  continue  for  some 
time  after  the  birth  of  the  child. 

6th  Month.  Weight  about  one  pound.  Length,  eleven  to  twelve 
and  a  half  inches.  The  hair  is  darker.  The  eyelids  are  closed,  and 
the  membrana  pupillaris  exists;  eyelashes  have  now  been  formed. 
Some  fat  is  deposited  under  the  skin.  The  testicles  are  still  in  the 
abdominal  cavity.  The  clitoris  is  prominent.  The  pubic  bones  have 
begun  to  ossify. 


124  PREGNANCY. 

7th  Month.  Weight  from  three  to  four  pounds.  Length,  thirteen 
to  fifteen  inches.  The  skin  is  covered  with  unctuous,  sebaceous  matter, 
and  there  is  a  more  considerable  deposit  of  subcutaneous  fat.  The 
eyelids  are  open.  The  testicles  have  descended  into  the  scrotum. 
Children  born  at  this  time  may  occasionally  survive. 

8th  Month.  Weight  from  four  to  five  pounds.  Length,  sixteen  to 
eighteen  inches,  and  the  foetus  seems  now  to  grow  in  thickness  rather 
than  in  length.  The  nails  are  completely  developed.  The  membrana 
pupillaris  has  disappeared. 

Foetus  at  Term. — At  the  completion  of  pregnancy  the  foetus  weighs 
on  an  average,  six  and  a  half  pounds,  and  measures  about  twenty 
inches  in  length.  These  averages  are,  however,  liable  to  great  varia- 
tion. Remarkable  histories  are  given  by  many  writers  of  foetuses  of 
extraordinary  weight,  which  have  been  probably  greatly  exaggerated. 
Out  of  3000  children  delivered  under  the  care  of  Cazeaux  at  various 
charities,  one  only  weighed  ten  pounds.  There  are,  however,  several 
carefully  recorded  instances  of  weight  far  exceeding  this ;  but  they  are 
undoubtedly  much  more  uncommon  than  is  generally  supposed.  Dr. 
Ramsbottom  mentions  a  foetus  weighing  sixteen  and  a  half  pounds ; 
Cazeaux  tells  us  of  one  which  he  delivered  by  turning,  which  weighed 
eighteen  pounds  and  measured  two  feet  one  and  a  half  inches;  and 
the  birth  of  one  weighing  twenty-one  pounds  has  been  recently 
recorded.1  Such  overgrown  children  are  almost  invariably  stillborn.2 

The  average  size  of  male  children  at  birth,  as  in  after-life,  is  some- 
what greater  than  that  of  female.  Thus  Simpson 3  found  that  out  of 
100  cases  the  male  children  averaged  ten  ounces  more  in  weight  than 
the  female,  and  half  an  inch  more  in  length. 

[Some  mothers  of  average  size  never  bear  a  foetus  of  even  six  pounds 
in  weight,  although  begotten  by  a  husband  of  full  vigor.  One  of  my 
patients  bore  a  daughter  of  three  and  a  half  pounds;  a  second  of  two 
and  three-quarters ;  and  a  son  of  five  and  a  half  pounds.  The  first 
daughter  has  given  birth  to  a  girl  of  one  and  a  half  pounds,  now  living 
at  the  age  of  two.  The  second  died  at  eight  months ;  and  the  son  is 
a  vigorous  youth  of  sixteen.  Such  small  children  sometimes  grow  to 
very  large  size  and  live  to  advanced  age,  as  witness  the  fact  that  one 
in  this  city  became  a  large,  tall  woman,  and  died  at  the  age  of  eighty- 
seven  years. — ED.] 

A  newborn  child  at  term  is  generally  covered  to  a  greater  or  less 
extent  with  a  greasy,  unctuous  material,  the  vernix  caseosa,  which  is 
formed  of  epithelial  scales  and  the  secretion  of  the  sebaceous  glands, 
and  which  is  said  to  be  of  use  in  labor  by  lubricating  the  surface  of 
the  child.  The  head  is  generally  covered  with  long  dark  hair,  which 

1  Brit.  Med.  Journ.,  Feb.  1,  1879. 

2  Probably  the  largest  fcetus  on  record  was  that  of  Mrs.  Captain  Bates,  the  Nova  Scotia  giantess, 
a  woman  of  seven  feet  nine  inches,  whose  husband  is  also  of  gigantic  build,  reaching  seven  feet 
seven  inches  in  height.    This  child,  born  in  Ohio,  was  their  second,  and  was  lost  in  its  birth,  as 
no  forceps  could  be  procured  of  sufficient  size  to  grasp  the  head.    The  foatus  weighed  twenty-three 
and  three-quarter  pounds,  and  was  thirty  inches  in  length.    Their  first  infant  weighed  eighteen 
pounds.    We  have  had  children  born  in  this  city  (Philadelphia)  at  maturity  and  live,  that  weighed 
out  one  pound.    The  well-remembered  "  Pincus  baby"  weighed  a  pound  and  an  ounce.    (Harris, 
note  to  3d  American  edition). 

3  Selected  Obstetrical  Works,  p.  327. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.         125 

frequently  falls  off  or  changes  in  color  shortly  after  birth.  Dr.  Wilt- 
shire1 has  called  attention  to  an  old  observation,  that  the  eyes  of  all 
newborn  children  are  of  a  peculiar  dark  steel-gray  color,  and  that 
they  do  not  acquire  their  permanent  tint  until  some  time  after  birth. 
The  umbilical  cord  is  generally  inserted  below  the  centre  of  the 
body. 

Anatomy  of  the  Foetal  Head. — The  most  important  part  of  the 
foetus  from  an,  obstetrical  point  of  view  is  the  head,  which  requires  a 
separate  study,  as  it  is  the  usual  presenting  part,  and  the  facility  of 
the  labor  depends  on  its  accurate  adaptation  to  the  maternal  passages. 

The  chief  anatomical  peculiarity  of  interest,  in  the  head  of  the  foatus 
at  term,  is  that  the  bones  of  the  skull,  especially  of  its  vertex — which, 
in  the  vast  majority  of  cases,  has  to  pass  first  through  the  pelvis — are 
not  firmly  ossified  as  in  adult  life,  but  are  joined  loosely  together  by 
membrane  or  cartilage.  The  result  of  this  is  that  the  skull  is  capable 
of  being  moulded  and  altered  in  form  to  a  very  considerable  extent  by 
the  pressure  to  which  it  is  subjected,,  and  thus  its  passage  through  the 
pelvis  is  very  greatly  facilitated.  This,  however,  is  chiefly  the  case 
with  the  cranium  proper,  the  bones  of  the  face  and  of  the  base  of  the 
skull  being  more  firmly  united.  By  this  means  the  delicate  structures 
at  the  base  of  the  brain  are  protected  from  pressure,  while  the  change 
of  form  which  the  skull  undergoes  during  labor  implicates  a  portion 
of  the  skull  where  pressure  on  the  cranial  contents  is  least  likely  to  be 
injurious. 

The  divisions  between  the  bones  of  the  cranium  are  further  of 
obstetric  importance  in  enabling  us  to  detect  the  precise  position  of  the 
head  during  labor,  and  an  accurate  knowledge  of  them  is  therefore 
essential  to  the  obstetrician. 

AVe  talk  of  them  as  sutures  and  fontandles:  the  former  being  the 
lines  of  junction  between  the  separate  bones,  which  overlap  each  other 
to  a  greater  or  less  extent  during  labor ;  the  latter,  membranous  inter- 
spaces where  the  sutures  join  each  other. 

The  principal  sutures  are:  1st.  The  sagittal,  which  separates  the 
two  parietal  bones,  and  extends  longitudinally  backward  along  the 
vertex  of  the  head.  2d.  The  frontal,  which  is  a  continuation  of  the 
sagittal,  and  divides  the  two  halves  of  the  frontal  bone,  at  this  time 
separate  from  each  other.  3d.  The  coronal,  which  separates  the  frontal 
from  the  parietal  bones,  and  extends  from  the  squamous  portion  of  the 
temporal  bone  across  the  head  to  a  corresponding  point  on  the  opposite 
side.  4th.  The  lambdoidal,  which  receives  its  name  from  its  resem- 
blance to  the  Greek  letter  A,  and  separates  the  occipital  from  the 
parietal  bones  on  either  side.  The  fontanelles  (Fig.  65)  are  the  mem- 
branous interspaces  where  the  sutures  join — the  anterior  and  larger 
being  lozenge-shaped,  and  formed  by  the  junction  of  the  frontal, 
sagittal,  and  two  halves  of  the  coronal  sutures.  It  will  be  well  to  note 
that  there  are,  therefore,  four  lines  of  sutures  running  into  it,  and  four 
angles,  of  which  the  anterior,  formed  by  the  frontal  suture,  is  most 
elongated  and  well  marked.  The  posterior  fontanelle  (Fig.  66)  is 

i  Lancet,  February  11, 1871. 


126 


PREGNANCY. 


formed  by  the  junction  of  the  sagittal  suture  with  the  two  legs  of  the 
lajabdoidal.  It  is,  therefore,  triangular  in  shape,  with  three  lines  of 
sutures  entering  it  in  three  angles,  and  is  much  smaller  than  the  an- 
terior fontanelle,  forming  merely  a  depression  into  which  the  tip  of  the 
finger  can  be  placed,  while  the  latter  is  a  hollow  as  big  as  a  shilling, 
or  even  larger.  As  it  is  the  posterior  fontanelle  which  is  generally 


FIG.  65. 


FIG.  66. 


Anterior  and  posterior  fontanelles. 


Bi-parietal  diameter,  sagittal  and 
lambdoidal  sutures,  with  posterior 
fontanelle. 


FIG.  67. 


lowest,  and  the  one  most  commonly  felt  during  labor,  it  is  important 
for  the  student  to  familiarize  himself  with  it,  and  he  should  lose  no 
opportunity  of  studying  the  sensations  imparted  to  the  finger  by  the 
sutures  and  fontanelles  in  the  head  of  the  child  after  birth. 

The  Diameters  of  the  Foetal  Skull. — For  the  purpose  of  under- 
standing the  mechanism  of  labor,  we  must  study  the  measurements  of 

the  fetal  head  in  relation  to  the 
cavity  through  which  it  has  to 
pass.  They  are  taken  from  .corre- 
sponding points  opposite  to  each 
other,  and  are  known  as  the 
diameters  of  the  skull  (Fig.  67). 
Those  of  most  importance  are  : 
1st.  The  occipito-mentalis  (o.  M), 
from  the  occipital  protuberance  to 
the  point  of  the  chin,  5.25"  to 
5.50".  2d.  The  octipito-frontalis 
(o.  F),  from  the  occiput  to  the 
centre  of  the  forehead,  4.50"  to 
5".-  3d.  The  sub-ocdpito-breg- 
matica  (s.o.  B),  from  a  point  mid- 
way between  the  occipital  pro- 
tuberance and  the  margin  of  the 
foramen  magnum  to  the  centre  of 

the  anterior  fontanelle,  3.25".  4th.  The  cervico-bregmatica  (C.B),  from 
the  anterior  margin  of  the  foramen  magnum  to  the  centre  of  the 
anterior  fontanelle,  3.75".  5th.  Transverse,  or  bi-parietalis  (BI-P), 


1—2.  Diameter  occipito-frontalis  (o.F). 
3 — 4.         "        occipito-mentalis  (O.M). 
5—6.         "        cervico-bregmatica  (C.B). 
7—8.         "        fronto-men  tails  (F.M). 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.          127 

between  the  parietal  protuberances,  3.75"  to  4".  6th.  Bi-temporalis 
(BI-T),  between  the  ears,  3.50".  7th.  Fronto-mentalis  (F.M),  from  the 
apex  of  the  forehead  to  the  chin,  3.25". 

The  length  of  these  respective  diameters,  as  given  by  different 
writers,  differs  considerably — a  fact  to  be  explained  by  the.  measure- 
ments having  been  taken  at  different  times ;  by  some  just  after  birth, 
when  the  head  was  altered  in  shape  by  the  moulding  it  had  undergone ; 
by  others  when  this  had  either  been  slight,  or  after  the  head  had 
recovered  its  normal  shape.  The  above  measurements  may  be  taken  as 
the  average  of  those  of  the  normally  shaped  head,  and  it  is  to  be 
noted  that  the  first  two  are  most  apt  to  be  modified  during  labor.  The 
amount  of  compression  and  moulding  to  which  the  head  may  be  sub- 
jected, without  proving  fatal  to  the  foetus,  is  not  certainly  known,  but 
it  is  doubtless  very  considerable.  Some  interesting  examples  of  the 
extent  to  which  the  head  may  be  altered  in  shape  in  difficult  labors 
have  been  given  by  Barnes,1  who  has  shown  by  tracings  of  the  shape 
of  the  head  taken  immediately  after  delivery,  that  in  protracted  labor 
the  occipito-mental  (o.  M)  and  occipito-frontal  (o.  F)  diameters  may  be 
increased  more  than  an  inch  in  length,  while  lateral  compression  may 
diminish  the  bi-parietal  (BI-P)  diameter  to  the  same  length  as  the 
inter-auricular.  The  foetal  head  is  movable  on  the  vertical  column  to 
the  extent  of  a  quarter  of  a  circle ;  and  it  seems  probable  that  the 
laxity  of  the  ligaments  admits  with  impunity  a  greater  circular  move- 
ment than  would  be  possible  in  the  adult. 

On  taking  the  average  of  a  large  number  of  measurements,  it  is 
found  that  the  heads  of  male  children  are  larger  and  more  firmly 
ossified  than  those  of  females,  the  former  averaging  about  half  an 
inch  more  in  circumference.  Sir  James  Simpson  attributed  great 
importance  to  this  fact,  and  believed  that  it  was  sufficient  to  account 
for  the  larger  proportion  of  stillbirths  in  male  than  in  female  chil- 
dren, as  well  as  for  the  greater  difficulty  of  labor  and  the  increased 
maternal  mortality  that  are  found  to  attend  on  male  births.  His 
well-known  paper  on  this  subject,  which"  has  given  rise  to  much  con- 
troversy, is  full  of  the  most  elaborate  details,  and  so  great  did  he 
believe  the  foetal  influence  to  be,  that  he  calculated  that  between 
the  years  1834  and  1837  there  were  lost  in  Great  Britain,  as  a  conse- 
quence of  the  slightly  larger  size  of  the  male  than  of  the  female  head 
at  birth,  about  50,000  lives,  including  those  of  about  46,000  or  47,000 
infants,  and  of  between  3000  and  4000  mothers  who  died  in  childbed.1 
It  is  probable  that  race  and  other  conditions,  such  as  civilization  and 
intellectual  culture,  have  considerable  influence  on  the  size  of  the  foetal 
skull,  but  we  are  not  in  possession  of  sufficiently  accurate  data  to  jus- 
tify any  very  positive  opinion  on  these  points. 

In  the  very  large  majority  of  cases  the  foetus  lies  in  utero  with  head 
downward,  and  is  so  placed  as  to  be  adapted  in  the  most  convenient 
way  to  the  cavity  in  which  it  is  placed.  The  uterine  cavity  is  most 
roomy  at  the  fundus,  and  narrowest  at  the  cervix,  and  the  greatest 
bulk  of  the  foetus  is  at  the  breech,  so  that  the  largest  part  of  the  child 

i  Obst.  Trans.,  1866,  vol.  vii.  p.  171.  *  Selected  Obst.  Works,  p.  363. 


128  PREGNANCY. 

usually  lies  in  the  part  of  the  uterus  best  adapted  to  contain  it.  The 
various  parts  of  the  child's  body  are,  further,  so  placed  in  regard  to 
each  other  as  to  take  up  the  least  possible  amount  of  space.  (See 
Plates  I.,  II.)  The  body  is  bent  so  that  the  spine  is  curved  with  its 
convexity  outward,  this  curvature  existing  from  the  earliest  period  of 
development;  the  chin  is  flexed  on  the  sternum;  the  forearms  are 
flexed  on  the  arms,  and.  lie  close  together  on  the  front  of  the  chest ; 
the  legs  are  flexed  on  the  thighs,  and  the  thighs  drawn  up  on  the 
abdomen  ;  the  feet  are  drawn  up  toward  the  legs ;  the  umbilical  cord 
is  generally  placed  out  of  reach  of  injurious  pressure,  in  the  'Space 
between  the  arms  and  the  thighs.  Variations  from  this  attitude, 
however,  are  not  uncommon,  and  are  not,  as  a  rule,  of  much  con- 
sequence. Although  the  cranial  presentations  are  much  the  most 
common,  averaging  86  out  of  every  100  cases,  other  presentations  are 
by  no  means  rare,  the  next  most  frequent  being  either  that  of  the 
breech,  in  which  the  long  diameter  of  the  child  lies  in  the  long  diam- 
eter of  the  uterine  cavity ;  or  some  variety  of  transverse  presentation, 
in  which  the  long  diameter  of  the  foetus  lies  obliquely  across  the  uterus, 
and  no  longer  corresponds  to  its  longitudinal  axis. 

It  was  long  believed  that  the  head  presentation  was  only  assumed 
toward  the  end  of  pregnancy,  when  it  was  supposed  to  be  produced 
by  a  sudden  movement  on  the  part  of  the  foetus,  known  as  the  eulbute. 
It  is  now  well  known  that,  in  the  large  majority  of  cases,  the  head  is 
lowest  during  all  the  latter  part  of  pregnancy,  although  changes  in 
position  are  more  common  than  is  generally  believed  to  be  the  case, 
and  presentation  of  parts  other  than  the  head  is  much  more  frequent 
in  premature  labor  than  in  delivery  at  term.  In  evidence  of  the  last 
statement,  Churchill  says  that  in  labor  at  the  seventh  month  the  head 
presents  only  83  times  out  of  100  when  the  child  is  living,  and  that 
as  many  as  53  per  cent,  of  the  presentations  are  preternatural  when 
the  child  is  stillborn.  The  frequency  with  which  the  foetus  changes 
its  position  before  delivery  has  been  made  the  subject  of  investigation 
by  various  German  obstetricians,  and  the  fact  can  be  readily  ascertained 
by  examination.  Yalenta1  found  that  out  of  nearly  1000  cases,  care- 
fully and  frequently  examined  by  him,  in  57.6  per  cent,  the  presenta- 
tion underwent  no  change  in  the  latter  months  of  pregnancy,  but  in 
the  remaining  42.4  per  cent,  a  change  could  be  readily  detected. 
These  alterations  were  found  to  be  most  frequent  in  multipart,  and 
the  tendency  was  for  abnormal  presentations  to  alter  into  normal  ones. 
Thus  it  was  common  for  transverse  presentations  to  alter  longitudinally, 
and  but  rare  for  breech  presentations  to  change  into  head.  The  ease 
with  which  these  changes  are  effected  no  doubt  depends,  in  a  con- 
siderable degree,  on  the  laxity  of  the  uterine  parietes,  and  on  the 
greater  quantity  of  amniotic  fluid,  by  both  of  which  the  free  mobility 
of  the  foetus  is  favored. 

The  facility  with  which  the  position  of  the  foetus  in  utero  can  be 
ascertained  by  abdominal  palpation  has  not  been  generally  appreciated 

1  Monats.  f.  Geburt.,  1865,  Bd.  xxiv.  S.  172;  and  1866,  Bd.  xxviii.    S.  361.     "  Geburtshiilfliche 
Studien." 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.          129 

in  obstetric  works,  and  yet,  by  a  little  practice,  it  is  easy  to  make  it 
out.  Much  information  of  importance  can  be  gained  in  this  way,  and 
it  is  quite  possible,  under  favorable  circumstances,  to  alter  abnormal 
presentations  before  labor  has  begun.  For  the  purpose  of  making 
this  examination,  the  patient  should  lie  at  the  edge  of  the  bed,  with 
her  shoulders  slightly  raised,  and  the  abdomen  uncovered.  The  first 
observation  to  make  is  to  see  if  the  longitudinal  axis  of  the  uterine 
tumor  corresponds  with  that  of  the  mother's  abdomen ;  if  it  does,  the 
presentation  must  be  either  a  head  or  a  breech.  By  spreading  the 
hands  over  the  uterus  (Fig.  68),  a  greater  sense  of  resistance  can  be 

FIG.  68. 


Mode  of  ascertaining  the  position  of  the  foetus  bv  palpation. 

felt,  in  most  cases,  on  one  side  than  on  the  other,  corresponding  to  the 
back  of  the  child.  By  striking  the  tips  of  the  fingers  suddenly  inward 
at  the  fundus,  the  hard  breech  can  generally  be  made  out,  or  the  head 
still  more  easily,  if  the  breech  be  do\vnward.  When  the  uterine  walls 
are  unusually  lax,  it  is  often  possible  to  feel  the  limbs  of  the  child. 
These  observations  can  be  generally  corroborated  by  auscultation,  for 
in  head  presentations  the  foetal  heart  can  usually  be  heard  below  the 
umbilicus,  and  in  breech  cases  above  it.  Transverse  presentations  can 
even  more  easily  be  made  out  by  abdominal  palpation.  Here  the 
long  axis  of  the  uterine  tumor  does  not  correspond  with  the  long  axis 
of  the  mother's  abdomen,  but  lies  obliquely  across  it.  By  palpation 
tin-  rounded  mass  of  the  head  can  be  easily  felt  in  one  of  the  mother's 
flanks,  and  the  breech  in  the  other,  while  the  foetal  heart  is  heard 
pulsating  nearer  to  the  side  at  which  the  head  is  detected. 

The  reason  why  the  head  presents  so  frequently  has  been  made  the 
subject  of  much  cliscussion.  The  oldest  theory  was,  that  the  head  lay 
over  the  os  uteri  as  the  result  of  gravitation,  and  the  influence  of 
gravity,  although  contested  by  many  obstetricians,  prominent  among 
whom  were  Dubois  and  Simpson,  has  been  insisted  upon  as  the  chief 


130 


PREGNANCY. 


cause  by  others,  Dr.  Duncan  being  one  of  the  most  strenuous  advo- 
cates of  this  view.  The  objections  urged  against  the  gravitation  theory 
were  drawn  partly  from  the  result  of  experiments,  and  partly  from 
the  frequency  with  which  abnormal  presentations  occur  in  premature 
labors,  when  the  action  of  gravity  cannot  be  supposed  to  be  suspended. 
The  experiments  made  by  Dubois  went  to  show,  that  when  the  foetus 
was  suspended  in  water,  gravitation  caused  the  shoulders,  and  not  the 
head,  to  fall  lowest.  He,  therefore,  advanced  the  hypothesis  that  the 
position  of  the  foetus  was  due  to  instinctive  movements,  which  it  made 
to  adapt  itself  to  the  most  comfortable  position  in  which  it  could  lie. 
It  need  only  be  remarked  that  there  is  not  the  slightest  evidence  of 
the  foetus  possessing  any  such  power.  Simpson  proposed  a  theory 
which  was  much  more  plausible.  He  assumed  that  the  foetal  position 
was  due  to  reflex  movements  produced  by  physical  irritations  to 
which  the  cutaneous  surface  of  the  foetus  is  subjected  from  changes 
of  the  mother's  position,  uterine  contractions,  and  the  like.  The 
absence  of  these  movements,  in  the  case  of  the  death  of  the  foetus, 
would  readily  explain  the  frequency  of  malpresentations  under  such 
circumstances. 

The  obvious  objection  to  this  theory,  complete  as  it  seems  to  be,  is 
the  absence  of  any  proof  that  such  constant  extensive  reflex  movements 


Diagram  illustrating  the  effect  of  gravity  on  the  foetus,  a,  b,  is  parallel  to  the  axis  of  the  preg- 
nant uterus  and  pelvic  brim  c,  d,  e,  is  a  perpendicular  line,  e,  the  centre  of  gravity  of  the 
foetus,  d,  the  centre  of  flotation.  (After  DUNCAN.) 

really  do  occur  in  utero.  Dr.  Duncan  has  very  conclusively  disposed 
of  the  principal  objections  which  have  been  raised  against  the  influence 
of  gravitation,  and,  when  an  obvious  explanation  of  so  simple  a  kind 
exists,  it  seems  useless  to  seek  further  for  another.  He  has  shown 
that  Dubois's  experiments  did  not  accurately  represent  the  state  of  the 
foetus  in  utero,  and  that  during  the  greater  part  of  the  day,  when  the 
woman  is  upright,  or  lying  on  her  back,  the  foetus  lies  obliquely  to 
the  horizon  at  an  angle  of  about  30°.  The  child  thus  lies,  in  the 
former  case,  on  an  inclined  plane,  formed  by  the  anterior  uterine  wall 


ANATOMY    AND    PHYSIOLOGY    OF    THE    F03TUS.          131 

and  the  abdominal  parietes,  in  the  latter  by  the  posterior  uterine 
wall  and  the  vertebral  column.  Down  the  inclined  plane  so  formed 
the  force  of  gravity  causes  the  foetus  to  slide,  and  it  is  only  when  the 
woman  lies  on  her  side  that  the  foetus  is  placed  horizontally,  and  is 
not  subjected  in  the  same  degree  to  the  action  of  gravity  (Fig.  69). 
The  frequency  of  mal-preseutatious  in  premature  labors  is  explained 
by  Dr.  Duncan  partly  by  the  fact  that  the  death  of  the  child  (which 
so  frequently  precedes  such  cases)  alters  its  centre  of  gravity,  and 
partly  by  the  greater  mobility  of  the  child  and  the  greater  relative 
amount  of  liquor  anmii  (Fig.  70).  The  effect  of  gravitation  is  probably 


Illustrating  the  greater  mobility  of  the  foetus  and  the  larger  relative  amount  of  liquor  amnii  in 
early  pregnancy,    a,  b.  Axis  of  pregnant  uterus.    6,  h.  A  horizontal  line.    (After  DUNCAN.) 

greatly  assisted  by  the  contractions  of  the  uterus  which  are  going  on 
during  the  greater  part  of  pregnancy.  The  influence  of  these  was 
pointed  out  by  Dr.  Tyler  Smith,  who  distinctly  showed  that  the  contrac- 
tions of  the  uterus  preceding  delivery  exerted  a  moulding  or  adapting 
influence  on  the  foetus,  and  prevented  undue  alterations  of  its  position. 
Dr.  Hicks  proved l  that  these  uterine  contractions  are  of  constant  occur- 
rence from  the  earliest  period  of  pregnancy,  and  there  can  be  little 
doubt  that  they  must  have  an  important  influence  on  the  body  contained 
within  the  uterus.  The  whole  subject  has  been  recently  considered 
by  Pinard,2  who  shows  that  many  factors  are  in  action  to  produce  and 
maintain  the  usual  position  of  the  foetus  in  utero,  which  may  be  either 
of  an  active  or  a  passive  character  :  the  former  being  chiefly  the  active 
movements  of  the  foetus  and  the  contractions  of  the  uterus  and  the 
abdominal  muscles ;  the  latter,  the  form  of  the  uterus  and  the  foetus, 
the  slippery  surface  of  the  amnion,  pressure  of  the  amniotic  fluid,  etc. 
When  any  of  these  factors  are  at  fault,  mal-presentation  is  apt  to 
occur. 

The  functions  of  the  foetus  are  in  the  main  the  same,  with  differ- 
ences depending  on  the  situation  in  which  it  is  placed,  as  those  of  the 
separate  being.  It  breathes,  it  is  nourished,  it  forms  secretions,  and 

i  Obst.  Trans.,  1872.  vol.  xiii.  p.  216. 
»  Annal.  de  Gyn.,  1878,  torn.  ix.  p.  321. 


132  PREGNANCY. 

its  nervous  system  acts.     The  mode  in  which  some  of  these  functions 
are  carried  on  in  intra-uterine  life  requires  separate  consideration. 

Nutrition. — During  the  early  part  of  pregnancy,  and  before  the 
formation  of  the  umbilical  vesicle  and  the  allantois,  it  is  certain  that 
nutritive  material  must  be  supplied  to  the  ovum  by  endosmosis 
through  its  external  envelope.  The  precise  source,  however,  from 
which  this  is  obtained  is  not  positively  known.  By  some  it  is  believed 
to  be  derived  from  the  granulations  of  the  discus  proligerus  which 
surround  it  as  it  escapes  from  the  Graafian  follicle,  and  subsequently 
from  the  layer  of  albuminous  matter  which  surrounds  the  ovum  before 
it  reaches  the  uterus ;  while  others  think  it  probable  that  it  may  come 
from  a  special  liquid  secreted  by  the  interior  of  the  Fallopian  tube  as 
the  ovum  passes  along  it.  As  soon  as  the  ovum  has  reached  the 
uterus,  there  is  every  reason  to  believe  that  the  umbilical  vesicle  is  the 
chief  source  of  nourishment  to  the  embryo,  through  the  channel  of 
the  omphalo-mesenteric  vessels,  which  convey  matters  absorbed  from 
the  interior  of  the  vesicle  to  the  intestinal  canal  of  the  foetus.  At  this 
time  the  exterior  of  the  ovum  is  covered  by  numerous  fine  villosities 
of  the  primitive  chorion,  which  are  imbedded  in  the  mucous  mem- 
brane of  the  uterus,  and  it  is  thought  that  they  may  absorb  materials 
from  the  maternal  system,  which  may  be  either  directly  absorbed  by 
the  embryo,  or  which  may  serve  the  purpose  of  replacing  the  nutritive 
matter  which  has  been  removed  from  the  umbilical  vesicle  by  the 
omphalo-mesenteric  vessels.  This  point  it  is,  of  course,  impossible  to 
decide.  Joulin,  however,  thinks  that  these  villi  probably  have  no 
direct  influence  on  the  nourishment  of  the  foetus,  which  is  at  this  time 
solely  effected  by  the  umbilical  vesicle,  but  that  they  absorb  fluid  from 
the  maternal  system,  which  passes  through  the  amnion  and  forms  the 
liquor  amuii.  As  soon  as  the  allautois  is  developed,  vascular  com- 
munication between  the  foetus  and  the  maternal  structures  is  estab- 
lished, and  the  temporary  function  of  the  umbilical  vesicle  is  over ; 
that  structure,  therefore,  rapidly  atrophies  and  disappears,  and  the 
nutrition  of  the  foetus  is  now  solely  carried  on  by  means  of  the  chorion 
villi,  lined  as  they  now  are  by  the  vascular  endochorion,  and  chiefly 
by  those  which  go  to  form  the  substance  of  the  placenta. 

This  statement  is  opposed  to  the  views  of  many  physiologists,  who 
believe  that  a  certain  amount  of  nutritive. material  is  conveyed  to  the 
foetus  through  the  channel  of  the  liquor  amnii,  itself  derived  from  the 
maternal  system,  which  is  supposed  either  to  be  absorbed  through 
the  cutaneous  surface  of  the  foetus,  or  carried  to  the  intestinal  canal 
by  deglutition.  The  reasons  for  assigning  to  the  liquor  amnii  a  nutri- 
tive function  are,  however,  so  slight,  that  it  is  difficult  to  believe  that  it 
has  any  appreciable  action  in  this  way.  They  are  based  on  some  ques- 
tionable observations,  such  as  those  of  AVeydlich,  who  kept  a  calf  alive 
for  fifteen  days  by  feeding  it  solely  on  liquor  amnii,  and  the  experi- 
ments of  Burdach,  who  found  the  cutaneous  lymphatics  engorged  in  a 
foetus  removed  from  the  amniotic  cavity,  while  those  of  the  intestine 
were  empty.  The  deglutition  of  the  liquor  amnii  for  the  purposes  of 
nutrition  has  been  assumed  from  its  occasional  detection  in  the  stomach 
of  the  foetus,  the  presence  of  which  may,  however,  be  readily  explained 


ANATOMY    AND     PHYSIOLOGY    OF    THE     F(ETUS.          133 

by  spasmodic  efforts  at  respiration,  which  the  foetus  undoubtedly  often 
makes  before  birth,  especially  when  the  placental  circulation  is  in  any 
way  interfered  with,  and  during  which  a  certain  quantity  of  fluid 
would  necessarily  be  swallowed.  The  quantity  of  nutritive  material, 
however,  in  the  liquor  auinii  is  so  small — not  more  than  6  to  9  parts 
of  albumin  in  1000 — that  it  is  impossible  to  conceive  that  it  could 
have  any  appreciable  influence  in  nutrition,  even  if  its  absoption 
either  by  the  skin  or  stomach  were  susceptible  of  proof. 

That  the  nutrition  of  the  foetus  is  effected  through  the  placenta  is 
proved  by  the  common  observation  that  whenever  the  placental  circu- 
lation is  arrested,  as  by  disease  of  its  structure,  the  foetus  atrophies 
and  dies.  The  precise  mode,  however,  in  which  nutritive  materials 
are  absorbed  from  the  maternal  blood  is  still  a  matter  of  doubt,  and 
must  remain  so  until  the  mooted  points  as  to  the  minute  anatomy  of 
the  placenta  are  settled.  The  various  theories  entertained  on  this 
subject  by  the  upholders  of  the  Hunterian  doctrine  of  placental 
anatomy,  and  by  those  who  deny  the  existence  of  a  sinus  system,  have 
already  been  referred  to  in  the  chapter  on  the  Anatomy  of  the 
Placenta,  to  which  the  reader  is  referred  (pp.  115-122). 

Respiration. — One  of  the  chief  functions  of  the  placenta,  besides 
that  of  nutrition,  is  the  supply  of  oxygenated  blood  to  the  foetus. 
That  this  is  essential  to  the  vitality  of  the  foetus,  and  that  the  placenta 
is  the  site  of  oxygenation,  is  shown  by  the  fact  that  whenever  the 
placenta  is  separated,  or  the  access  of  foetal  blood  to  it  arrested  by 
compression  of  the  cord,  instinctive  attempts  at  inspiration  are  made, 
and  if  aerial  respiration  cannot  be  performed,  the  foetus  is  expelled 
asphyxiated.  Like  the  other  functions  of  the  foetus  during  intra- 
uterine  life,  that  of  respiration  has  been  made  the  subject  of  numerous 
more  or  less  ingenious  hypotheses.  Thus  many  have  believed  that 
the  foetus  absorbed  gaseous  material  from  the  liquor  amnii,  which 
served  the  purpose  of  oxygenating  its  blood,  St.  Hilaire  thinking  that 
this  was  effected  by  minute  openings  in  its  skin,  Beclard  and  others 
through  the  bronchi,  to  which  they  believed  the  liquor  amnii  gained 
access.  Independently  of  the  entire  want  of  evidence  of  the  absorption 
of  gaseous  materials  by  these  channels,  the  theory  is  disproved  by  the 
fact  that  the  liquor  amnii  contains  no  air  which  is  capable  of  respira- 
tion. Serres  attributed  a  similar  function  to  some  of  the  chorion  villi, 
which  he  believed  penetrated  the  utricular  glands  of  the  decidua  reflexa 
and  absorbed  gas  from  the  hydroperione,  or  fluid  situated  between 
it  and  the  decidua  vera,  and  in  this  manner  he  thought  the  foetal  blood 
was  oxygenated  until  the  fifth  month  of  intra-uterine  life,  when  the 
placenta  was  fully  formed. 

This  hypothesis,  however,  rests  on  no  accurate  foundation,  for  it  is 
certain  that  the  chorion  villi  do  not  penetrate  the  utricular  glands  in  the 
manner  assumed  ;  or,  even  if  they  did,  the  mode  in  which  the  oxygen 
thus  absorbed  by  the  chorion  villi  reaches  the  foetus,  which  is  separated 
from  them  by  the  amiiion  and  its  contents,  would  still  remain 
unexplained. 

The  mode  in  which  the  oxygenation  of  the  foetal  blood  is  effected 
before  the  formation  of  the  placenta  remains,  therefore,  as  yet  un- 


134 


PREGNANCY. 


known.  After  the  development  of  that  organ,  however,  it  is  less 
difficult  to  understand,  for  the  foetal  blood  is  everywhere  brought  into 
such  close  contact  with  the  maternal,  in  the  numerous  minute  ramifica- 
tions of  the  umbilical  vessels,  that  the  interchange  of  gases  can  readily 
be  effected.  The  activity  of  respiration  is  doubtless  much  less  than  in 
extra-uterine  life,  for  the  waste  of  tissue  in  the  fcetus  is  necessarily 
comparatively  small,  from  the  fact  of  its  being  suspended  in  a  fluid 
medium  of  its  own  temperature,  and  from  the  absence  of  the  processes 
of  digestion  and  of  respiratory  movements.  The  quantity  of  carbonic 
acid  formed  would,  therefore,  be  much  less  than  after  birth,  and  there 
would  be  a  correspondingly  small  call  for  oxygeuation  of  venous 
circulation. 

Circulation. — The  functions  of  the  lungs  being  in  abeyance,  it  is 
necessary  that  all  the  foetal  blood  should  be  carried  to  the  placenta 
to  receive  oxygen  and  nutritive  materials.  To  understand  the  mode 
in  which  this  is  effected  we  must  bear  in  mind  certain  peculiarities  in 
the  circulatory  system  which  disappear  after  birth. 

1.  The  two  sides  of  the  foetal  heart  are  not  separate  as  in  the  adult. 
The  right  ventricle  in  the  adult  sends  all  the  venous  blood  to  the 
lungs  through  the  pulmonary  arteries,  to  be  aerated  by  contact  with 
the  atmosphere.    In  the  foetus,  however,  only  sufficient  blood  is  passed 
through  the  pulmonary  arteries  to  insure  their  being  pervious  and 
ready  to  carry  blood  to  the  lungs  immediately  after  birth. 

An  aperture  of  communication,  the  foramen  ovale,  exists  between  the 
two  auricles,  w-hich  is  arranged  so  as  to  permit  the  blood  reaching  the 
right  auricle  to  pass  freely  into  the  left,  but  not  vice  versa.  By  this 
means  a  large  portion  of  the  blood  reaching  the  heart  through  the 
vena?  cavse,  instead  of  passing,  as  in  the  adult,  into  the  right  ventricle, 
is  directed  into  the  right  auricle. 

2.  Even  with  this  arrangement,  however,  a  larger  portion  of  blood 
would  pass  into  the  pulmonary  arteries  than  is  required  for  trans- 
mission to  the  lungs,  and  a  further  provision  is  made  to  prevent  its 

going  to  them  by  means  of  a  foetal  vessel,  the 
ductus  arteriosus  (Fig.  71),  which  arises  from  the 
point  of  bifurcation  of  the  pulmonary  arteries, 
and  opens  into  the  arch  of  the  aorta.  In  con- 
sequence of  this  arrangement  only  a  very  small 
portion  of  the  blood  reaches  the  lungs  at  all. 

3.  The  foetal  hypogastric  arteries  are  continued 
into  large  arterial  trunks,  which,  passing  into  the 
cord,  form  the  umbilical  arteries,  and  carry  the 
impure  foetal  blood  into  the  placenta. 

4.  The   purified    blood    is   collected    into    the 
single  umbilical  vein,  through  which  it  is  carried 
to  the  under  surface  of  the  liver,  from  which  point 
it  is  conducted,  by  means  of  another  special  foetal 

vessel,  the  ductus  venosus,  into  the  ascending  vena  cava  and  the  right 
auricle. 

In  order  to  understand  the  course  of  the  foetal  blood  it  may  be 
most  conveniently  traced  from  the  point  where  it  reaches  the  under 


FIG.  71. 


Diagram  of  foetal  heart. 
1.  Aorta.  2.  Pulmonary 
artery.  3,  3.  Pulmonary 
branches.  4.  Ductus  ar- 
teriosus. (After  DALTON.) 


ANATOMY  AND  PHYSIOLOGY  OF  THE  F(ETUS.    135 

surface  of  the  liver  through  the  umbilical  vein.  Part  of  it  is  dis- 
tributed to  the  liver  itself,  but  the  greater  quantity  is  carried  directly  into 
the  inferior  vena  cava,  through  the  ductus  venosus.  The  inferior  vena 
cava  also  receives  the  blood  from  the  foetal  veins  of  the  lower  extremi- 
ties, and  that  portion  of  the  blood  of  the  umbilical  vein  which  lias 
passed  through  the  liver.  This  mixed  blood  is  carried  up  to  the  right 
auricle,  from  which  by  far  the  greater  part  of  it  is  immediately  directed 
into  the  left  auricle,  through  the  foramen  ovale.  From  thence  it 
passes  into  the  left  ventricle,  which  sends  the  greater  part  of  it  into  the 
head  and  upper  extremities  through  the  aorta,  a  comparatively  small 
quantity  being  transmitted  to  the  inferior  extremities.  The  blood 
which  is  thus  sent  to  the  upper  part  of  the  body  is  collected  into  the 
vena  cava  superior,  by  which  it  is  thrown  into  the  right  auricle. 
Here  the  mass  of  it  is  probably  directed  into  the  right  ventricle,  which 
expels  it  into  the  pulmonary  arteries,  and  from  thence,  through  the 
ductus  arteriosus,  into  the  descending  aorta.  By  this  arrangement  it 
will  be  seen  that  the  descending  aorta  conveys  to  the  lower  part  of  the 
body  the  comparatively  impure  blood  which  has  already  circulated 
through  the  head,  neck,  and  upper  extremities.  From  the  descending 
aorta  a  small  quantity  of  blood  is  conveyed  to  the  lower  extremities, 
the  greater  part  of  it  being  carried  for  purification  to  the  placenta 
through  the  umbilical  arteries. 

As  soon  as  the  child  is  born  it  generally  cries  loudly  and  inflates 
its  lungs,  and,  in  consequence,  the  pulmonary  arteries  are  dilated  and 
the  greater  portion  of  the  blood  of  the  right  ventricle  is  at  once  sent 
to  the  lungs,  from  whence,  after  being  arterialized,  it  is  returned  to 
the  left  auricle,  through  the  pulmonary  veins.  The  left  auricle,  there- 
fore, receives  more  blood  than  before,  the  right  less,  and,  the  placental 
circulation  being  arrested,  no  more  passes  through  the  umbilical  vein. 
In  consequence  of  this,  the  pressure  of  the  blood  in  the  two  auricles  is 
equalized,  the  mass  of  the  blood  in  the  right  auricle  no  longer  passes 
into  the  left  (the  valve  of  the  foramen  ovale  being  closed  by  the  equal 
pressure  on  both  sides),  but  directly  into  the  right  ventricle  and  from 
thence  into  the  pulmonary  arteries,  and  the  ductus  arteriosus  soon 
collapses  and  becomes  impervious.  The  mass  of  blood  in  the  descending 
aorta  no  longer  finds  its  way  into  the  hypogastric  arteries,  but  passes 
into  the  lower  extremities,  and  the  adult  circulation  is  established. 

The  changes  which  take  place  in  the  temporary  vascular  arrange- 
ments in  the  foetus,  prior  to  their  complete  disappearance,  are  of  some 
practical  interest.  The  ductus  arteriosus,  as  has  been  said,  collapses, 
chiefly  because  the  mass  of  blood  is  drawn  to  the  lungs,  and  partly, 
perhaps,  by  its  own  inherent  contractility.  Its  walls  are  found  to  be 
thickened,  and  its  canal  closes,  first  in  the  centre,  and  subsequently  at 
its  extremities,  its  aortic  end  remaining  longer  pervious  on  account  of 
the  greater  pressure  of  blood  from  the  left  side  of  the  heart  (Fig.  72). 
Practical  closure  occurs  .within  a  few  days  after  birth,  although 
Flourens  states  that  it  is  not  completely  obliterated  until  eighteen  months 
or  two  years  have  elapsed,1  According  to  Schroeder  its  walls  unite 

*  Acad.  des  Sciences,  1854. 


136 


PREGNANCY. 


FIG.  72. 


Diagram  of  heart  of  infant.  1. 
Aorta.  2.  Pulmonary  artery.  3,  3. 
Pulmonary  branches.  4.  Ductus 
arteriosus  becoming  obliterated. 
(After  DALTON.) 


without  the  formation  of  any  thrombus.  The  foramen  ovale  is  soon 
closed  by  its  valve,  which  contracts  adhesion  with  the  edges  of  the 
aperture,  so  as  effectually  to  occlude  it.  Sometimes,  however,  a  small 

canal  of  communication  between  the  two 
auricles  may  remain  pervious  for  many 
months,  or  even  a  year  or  more,  without, 
however,  any  admixture  of  blood  occurring. 
A  permanently  patulous  condition  of  this 
aperture,  however,  sometimes  exists,  giving 
rise  to  the  disease  known  as  cyanosis. 

The  umbilical  arteries  and  veins  and  the 
ductus  venosus  soon  also  become  imper- 
meable, in  consequence  of  concentric  hyper- 
trophy of  their  tissue  and  collapse  of  their 
wralls.  The  closure  of  the  former  is  aided 
by  the  formation  of  coagula  in  the  interior. 
According  to  Robin,  a  longer  time  than  is 
usually  supposed  elapses  before  they  become 
completely  closed,  the  vein  remaining  per- 
vious until  the  twentieth  or  thirtieth  day 
after  delivery,  the  arteries  for  a  month  or  six  weeks.  He  has  also 
described1  a  remarkable  contraction  of  the  umbilical  vessels  within 
their  sheaths,  at  the  point  wrhere  they  leave  the  abdominal  walls, 
which  takes  place  within  three  or  four  days  after  birth,  and  seems  to 
prevent  hemorrhage  taking  place  when  the  cord  is  detached. 

Function  of  the  Liver. — The  liver,  from  its  proportionately  large 
size,  apparently  plays  an  important  part  in  the  foetal  economy.  It  is 
not  until  about  the  fifth  month  of  utero-gestation  that  it  assumes  its 
characteristic  structure,  and  forms  bile,  previous  to  that  time  its  texture 
being  soft  and  undeveloped.  According  to  Claude  Bernard,  after  this 
period  one  of  its  most  important  offices  is  the  formation  of  sugar,  which 
is  found  in  much  larger  amount  in  the  foetus  than  after  birth.  Sugar 
is,  however,  found  in  the  foetal  structures  long  before  the  development 
of  the  liver,  especially  in  the  mucous  and  cutaneous  tissues,  and  it 
seems  probable  that  these,  as  well  as  the  placenta  itself,  then  fulfil  the 
glycogenic  function,  afterward  chiefly  performed  by  the  liver.  The 
bile  is  secreted  after  the  fifth  month  of  pregnancy,  and  passes  into  the 
intestinal  canal,  and  is  subsequently  collected  in  the  gall-bladder.  By 
some  physiologists  it  has  been  supposed  that  the  liver,  during  intra- 
uterine  life,  was  the  chief  seat  of  depuration  of  the  carbonic  acid 
contained  in  the  venous  blood  of  the  foetus.  It  is,  however,  more 
generally  believed  that  this  is  accomplished  solely  in  the  placenta. 
The  bile,  mixed  with  the  mucous  secretion  of  the  intestinal  tract,  forms 
the  meconium  which  is  contained  in  the  intestines  of  the  foetus,  and 
which  collects  in  them  during  the  whole  period  of  intra-uterine  life. 
It  is  a  thick,  tenacious,  greenish  substance,  which  is  voided  soon  after 
birth  in  considerable  quantity. 

The  Urine. — Urine  is  certainly  formed  during  intra-uterine  life,  as. 


Ibid.,  1860. 


PREGNANCY.  137 

is  proved  by  the  fact  familiar  to  all  accoucheurs,  that  the  bladder  is  con- 
stantly emptied  instantly  after  birth.  It  has  generally  been  supposed 
that  the  foetus  voids  its  urine  into  the  cavity  of  the  amnion,  and  the 
existence  of  traces  of  urea  in  the  liquor  amnii,  as  well  as  some  cases  of 
imperforate  urethra,  in  which  the  bladder  was  found  to  be  enormously 
distended,  and  some  cases  of  congenital  hydro-nephrosis  associated  with 
impervious  ureters,  have  been  supposed  to  corroborate  this  assumption. 
The  question  has  been  very  fully  studied  by  Joulin,  who  has  collected 
together  a  large  number  of  instances  in  which  there  was  imperforate 
urethra  without  any  undue  distention  of  the  bladder.  He  holds  also, 
that  the  amount  of  urea  found  in  the  liquor  amnii  is  far  too  minute  to 
justify  the  conclusion  that  the  urine  of  the  foetus  was  habitually  passed 
into  it,  although  a  small  quantity  may,  he  thinks,  escape  into  it  from 
time  to  time ;  and  he  therefore  believes  that  the  urine  of  the  foetus  is 
only  secreted  regularly  and  abundantly  after  birth,  and  that  during 
intra-uterine  life  its  retention  is  not  likely  to  give  rise  to  any  functional 
disturbance. 

Function  of  the  Nervous  System. — There  is  no  doubt  that  the 
nervous  system  acts  to  a  considerable  extent  during  intra-uterine  life, 
and  some  authors  have  even  supposed  that  the  foetus  was  endowed  with 
the  power  of  making  instinctive  or  voluntary  movements  for  the  pur- 
pose of  adapting  itself  to  the  form  of  the  uterine  cavity.  Most  prob- 
ably, however,  the  movements  the  foetus  performs  are  purely  reflex. 
That  it  responds  to  a  stimulus  applied  to  the  cutaneous  nerves  is  proved 
by  the  experiments  of  Tyler  Smith,  who  laid  bare  the  amnion  in  preg- 
nant rabbits,  and  found  that  the  foetus  moved  its  limbs  when  these 
were  irritated  through  it.  Pressure  on  the  mother's  abdomen,  cold 
applications,  and  similar  stimuli  will  also  produce  energetic  fcetal 
movements.  The  gray  matter  of  the  brain  in  the  newborn  child  is, 
however,  quite  rudimentary  in  its  structure,  and  there  is  no  evidence 
of  intelligent  action  of  the  nervous  system  until  some  time  after  birth, 
and  a  fortiori  during  pregnancy. 


CHAPTER   III. 

PKEGNANCY. 

Changes  in  the  Uterus. — As  soon  as  conception  has  taken  place  a 
series  of  remarkable  changes  commence  in  the  uterus,  which  progress 
until  the  termination  of  pregnancy,  and  are  Nwell  worthy  of  careful 
study.  They  produce  those  marvellous  modifications  which  effect  the 
transformation  of  the  small  undeveloped  uterus  of  the  non-pregnant 
state  into  the  large  and  fully  developed  uterus  of  pregnancy,  and  have 
no  parallel  in  the  whole  animal  economy. 


138 


PREGNANCY. 


A  knowledge  of  them  is  essential  for  the  proper  comprehension  of 
the  phenomena  of  labor,  and  for  the  diagnosis  of  pregnancy  which  the 
practitioner  is  so  frequently  called  upon  to  make.  Excluding  the 
varieties  of  abnormal  pregnancy,  which  will  be  noticed  in  another 
place,  Ave  shall  here  limit  ourselves  to  the  consideration  of  the  modifi- 
cations of  the  maternal  organism  which  result  from  simple  and  natural 
gestation. 

The  unimpregnated  uterus  measures  two  and  a  half  inches  in  length 
and  weighs  about  one  ounce,  while  at  the  full  term  of  pregnancy  it 
has  so  immensely  grown  as  to  weigh  twenty-four  ounces  and  measure 
twelve  inches.  The  growth  commences  as  soon  as  the  ovum  reaches 
the  uterus,  and  continues  uninterruptedly  until  delivery.  In  the  early 
months  the  uterus  is  contained  entirely  in  the  cavity  of  the  pelvis,  and 
the  increase  of  size  is  only  apparent  on  vaginal  examination,  and  that 
with  difficulty.  Before  the  third  month  the  enlargement  is  chiefly  in 


FIG.  73. 


Relations  of  the  pregnant  uterus  at  sixth  month  to  the  surrounding  parts. 
(After  MARTIN.) 

the  lateral  direction,  so  that  the  whole  body  of  the  uterus  assumes 
more  of  a  spherical  shape  than  in  the  non-pregnant  state.  If  an 
opportunity  of  examining  the  gravid  uterus  post  mortem  should  occur 
at  this  time,  it  will  be  found  to  have  the  form  of  a  sphere  flattened 
somewhat  posteriorly,  and  bulging  anteriorly. 


PREGNANCY. 


139 


FIG.  74. 


After  the  ascent  of  the  organ  into  the  abdomen  it  develops  more  in 
the  vertical  direction,  so  that  at  term  it  has  the  form  of  an  ovoid,  with 
its  large  extremity  above  and  its  narrow  end  at  the  cervix  uteri,  and 
its  longitudinal  axis  corresponds  to  the  long  diameter  of  the  mother's 
abdomen,  provided  the  presentation  be  either  of  the  head  or  breech. 
The  anterior  surface  is  now  even  more  distinctly  projecting  than  before 
— a  fact  which  is  explained  by  the  proximity  of  the  posterior  surface 
to  the  rigid  spinal  column  behind,  while  the  anterior  is  in  relation  with 
the  lax  abdominal  parietes,  which  yield  readily  to  pressure,  and  so 
allow  of  the  more  marked  prominence  of  the  anterior  uterine  wall. 

Before  the  gravid  uterus  has  risen  out  of  the  pelvis  no  appreciable 
increase  in  the  size  of  the  abdomen  is  perceptible.  On  the  contrary, 
it  is  an  old  observation  that  at  this  early  stage  of  pregnancy  the 
abdomen  is  flatter  than  usual,  on  account  of  the  partial  descent  of  the 
uterus  in  the  pelvic  cavity  as  a  result  of  its  increased  weight.  As  the 
growth  of  the  organ  advances,  it  soon  becomes  too  large  to  be  con- 
tained any  longer  within  the  pelvis,  and  about  the  middle  of  the  third 
or  the  beginning  of  the  fourth  month  the  fundus  rises  above  the  pelvic 
brim — not  suddenly,  as  is  often  erroneously  thought,  but  slowly  and 
gradually — when  it  may  be  felt  as  a  smooth  rounded  swelling. 

It  is  about  this  time  that  the  movements  of  the  foetus  first  become 
appreciable  to  the  mother,  when  "quickening"  is  said  to  have  taken 

place.  Toward  the  end  of  the  fourth 
month  the  uterus  reaches  to  about 
three  fingers'  breadth  above  the  sym- 
physis  pubis.  About  the  fifth  month 
it  occupies  the  hypogastric  region,  to 
which  it  imparts  a  marked  projection, 
and  the  alteration  in  the  figure  is  now 
distinctly  perceptible  to  visual  exami- 
nation. About  the  sixth  month  it  is 
011  a  level  with,  or  a  little  above,  the 
umbilicus  (Fig.  73).  About  the  sev- 
enth month  it  is  about  two  inches 
above  the  umbilicus,  which  is  now 
projecting  and  prominent,  instead  of 
depressed,  as  in  the  non-pregnant 
state.  During  the  eighth  and  ninth 
months  it  continues  to  increase  until 
the  summit  of  the  fundus  is  imme- 
diately below  the  ensiform  cartilage 
(Fig.  74).  A  more  accurate  estimate 

size  of.  uterus  at  various  periods  of        of  the  size  _of  the  uterine  tumor  at 
pregnancy.  various  periods  of  pregnancy  can  be 

obtained    by  measuring  the  distance 

between  the  fnndus  uteri  and  the  upper  margin  of  the  symphysis  pubis 
either  with  callipers  or  a  measuring  tape.  The  accompanying  table  gives 
the  dimensions  from  the  measurements  of  Spiegelberg1  and  Sutugiu:2 

1  Lehrbuch  der  Geb..  Bd.  ii.  S.  115. 

2  Obst.  Journ.  of  Great  Britain  and  Ireland,  1875,  vol.  ill. 


140 


PREGNANCY. 


SIZE  OP  UTERUS  AT  VARIOUS  STAGES  OF  PREGNANCY. 


Week  of  pregnancy. 

Height  of  fnndus  uteri 
above  pubes,  measured 
by  tape  (Spiegelberg). 

Height  of  fundus  uteri 
above  pubes,  measured 
by  callipers  (Sutugiu). 

22d  ) 
24th  V                  ;        

8.5  incl 

10.5 
11.0 
11.5 
12.0 
12.5 
13.0 
13.2 

ies          •< 

60  inc 
6.6 
7.3 
7.8 
8.3 
8.7 
9.0 
9.3 
9.6 
10.0 

Ml 

26th  I 
28th    .                 

30th            

32d      

34th    
36th    

38th    

40th    

The  former  employed  a  tape  measure,  the  latter  used  callipers,  and 
his  results  are,  therefore,  more  accurate. 

A  knowledge  of  the  size  of  the  uterine  tumor  at  various  periods  of 
pregnancy,  as  thus  indicated,  is  of  considerable  practical  importance, 
as  forming  the  only  guide  by  which  we  can  estimate  the  probable 
period  of  delivery  in  certain  cases  in  which  the  usual  data  for  calcu- 
lation are  absent,  as,  for  example,  when  the  patient  has  conceived 
during  lactation. 

For  about  a  week  or  more  before  labor  the  uterus  generally  sinks 
somewhat  into  the  pelvic  cavity,  in  consequence  of  the  relaxation  of 
the  soft  parts  which  precedes  delivery,  and  the  patient  now  feels  her- 
self smaller  and  lighter  than  before.  This  change  is  familiar  to  all 
childbearing  women,  to  whom  it  is  known  as  "  the  lightening  before 
labor." 

While  the  uterus  remains  in  the  pelvis  its  longitudinal  axis  varies 
in  direction,  much  in  the  same  way  as  that  of  the  non-pregnant  uterus, 
sometimes  being  more  or  less  vertical,  at  others  in  a  state  of  ante- 
version  or  partial  retroversion.  These  variations  are  probably  de- 
pendent on  the  distention  or  emptiness  of  the  bladder,  as  its  state 
must  necessarily  affect  the  position  of  the  movable  body  poised  behind 
it.  After  the  uterus  has  risen  into  the  abdomen,  its  tendency  is  to 
project  forward  against  the  abdominal  wall,  which  forms  its  chief 
support  in  front.  In  the  erect  position  the  long  axis  of  the  uterine 
tumor  corresponds  with  the  axis  of  the  pelvic  brim,  forming  an  angle 
of  about  30°  with  the  horizon.  In  the  semi-recumbent  position,  on 
the  other  hand,  as  Duncan1  has  pointed  out,  its  direction  becomes 
much  more  nearly  vertical.  In  women  who  have  borne  many  chil- 
dren, the  abdominal  parietes  no. longer  afford  an  efficient  support,  and 
the  uterus  is  displaced  anteriorly,  the  fundus  in  extreme  cases  even 
hanging  downward. 

In  addition  to  this  anterior  obliquity,  on  account  of  the  projection 
of  the  spinal  column,  the  uterus  is  very  generally,  also  displaced  lat- 
erally, and  sometimes  to  a  very  marked  degree,  so  that  it  may  be  felt 
entirely  in  one  flank,  instead  of  in  the  centre  of  the  abdomen.  In  a 
large  proportion  of  cases  this  lateral  deviation  is  to  the  right  side,  and 

1  Researches  in  Obstetrics,  p.  10. 


PREGNANCY.  141 

many  hypotheses  have  been  brought  forward  to  explain  this  fact,  none 
of  them  being  satisfactory.  Thus,  it  has  been  supposed  to  depend  on 
the  greater  frequency  with  which  women  lie  on  their  right  side  during 
sleep,  on  the  greater  use  of  the  right  leg  during  walking,  on  the  sup- 
posed comparative  shortness  of  the  right  round  ligament,  which  drags 
the  tumor  to  that  side,  or  on  the  frequent  disteution  of  the  rectum  on 
the  left  side,  which  prevents  the  uterus  being  displaced  in  that  direc- 
tion. Of  these  the  last  is  the  cause  which  seems  most  constantly  in 
operation,  and  most  likely  to  produce  the  eifect. 

The  cervix  must  obviously  adapt  itself  to  the  situation  of  the  body 
of  the  uterus.  We  find,  therefore,  that  in  the  early  months,  when  the 
uterus  lies  low  in  the  pelvis,  it  is  more  readily  within  reach.  After 
the  ascent  of  the  uterus,  it  is  drawn  up,  and  frequently  so  much  as  to 
be  reached  with  difficulty.  When  the  uterus  is  much  anteverted,  as  is 
so  often  the  case,  the  os  is  displaced  backward,  so  that  it  cannot  be  felt 
at  all  by  the  examining  finger. 

Toward  the  end  of  pregnancy  the  greater  part  of  the  anterior  sur- 
face of  the  uterus  is  in  contact  with  the  abdominal  wall,  its  lower 
portion  resting  on  the  posterior  surface  of  the  symphysis  pubis.  The 
posterior  surface  rests  on  the  spinal  column,  while  the  small  intestines 
are  pushed  to  either  side,  the  large  intestines  surrounding  the  uterus 
like  an  arch. 

Changes  in  the  Uterine  Parietes. — The  great  distention  of  the 
uterus  during  pregnancy  was  formerly  supposed  to  be  mainly  due  to 
the  mechanical  pressure  of  the  enlarging  ovum  within  it.  If  this 
were  so,  then  the  uterine  walls  would  be  necessarily  much  thinner 
than  in  the  non-pregnant  state.  This  is  well  known  not  to  be  the 
case,  and  the  immense  increase  in  the  size  of  the  uterine  cavity  13  to 
be  explained  by  the  hypertrophy  of  its  walls.  At  the  full  period  of 
pregnancy  the  thickness  of  the  uterine  parietes  is  generally  about  the 
same  as  that  of  the  non-pregnant  uterus,  rather  more  at  the  placental 
site,  and  less  in  the  neighborhood  of  the  cervix.  Their  thickness, 
however,  varies  in  different  places,  and  in  some  women  they  are  so 
thin  as  to  admit  of  the  fcetal  limbs  being  very  readily  made  out  by 
palpation.  Their  density  is,  howrever,  always  much  diminished,  and, 
instead  of  being  hard  and  inelastic,  they  become  soft  and  yielding  to 
pressure.  This  change  coincides  with  the  commencement  of  pregnancy, 
of  which  it  forms,  as  recognizable  in  the  cervix,  one  of  the  earliest 
diagnostic  marks.  At  a  more  advanced  period  it  is  of  value  as  admit- 
ting a  certain  amount  of  yielding  of  the  uterine  walls  to  movements 
of  the  foetus,  thus  lessening  the  chance  of  their  being  injured.  Bandl 
has  pointed  out  that  during  the  latter  months  of  pregnancy  the  lower 
segment  of  the  uterus,  to  a  distance  of  from  four  to  six  inches  above 
the  inner  os,  is  thinner  and  less  vascular  than  the  tissues  of  the  body 
of  the  uterus  above.  This  thinner  portion  is  separated  from  that  above 
it  by  a  ridge,  often  easily  made  out  when  the  hand  has  to  be  inserted 
into  the  uterus  after  delivery,  known  as  "Bandl's  ring."1 

1  Ueber  das  Verhalten  des  Uterus  und  Cervix  In  der  Schwangerschaft  und  wiihrend  der  Geburt. 
1876. 


142 


PREGNANCY. 


Changes  in  the  Cervix  during  Pregnancy. — Very  erroneous 
views  have  long  been  taught,  in  most  of  our  standard  works  on  mid- 
wifery, as  to  the  changes  which  occur  in  the  cervix  uteri  during  preg- 
nancy. It  is  generally  stated  that,  as  pregnancy  advances,  the  cervical 
cavity  is  greatly  diminished  in 'length,  in  consequence  of  its  being 
gradually  drawn  up  so  as  to  form  part  of  the  general  cavity  of  the 
uterus,  so  that  in  the  latter  months  it  no  longer  exists.  In  almost  all 


FIG.  75. 


FIG.  76. 


Supposed  shortening  of  the  cervix  at  the  third,  sixth,  eighth,  and  ninth  months  of  pregnancy, 
as  figured  in  obstetric  works. 

midwifery  works  accurate  diagrams  are  given  of  this  progressive  short- 
ening of  the  cervix  (Figs.  75  to  78).  The  cervix  is  generally  described 
as  having  lost  one-half  of  its  length  at  the  sixth  month,  two-thirds  at 
the  seventh,  and  to  be  entirely  obliterated  in  the  eighth  and  ninth. 
The  correctness  of  these  views  was  first  called  in  question  in  recent 
times  by  Stoltz,  in  1826,  but  Dr.  Duncan,1  in  an  elaborate  historical 
paper  on  the  subject,  has  shown  that  Stoltz  was  anticipated  by  "\Veit- 
brech  in  1750,  and  to  a  less  degree  by  Roederer  and  other  writers. 
Their  opinion  is  now  pretty  generally  admitted  to  be  correct,  and  is 
upheld  by  Cazeaux,  Arthur  Farre,  Duncan,  and  most  modern  obste- 
tricians. Indeed,  various  post-moriem  examinations  in  advanced  preg- 
nancy have  shown  that  the  cavity  of  the  cervix  remains  in  reality  of 
its  normal  length  of  one  inch,  and  it  can  often  be  measured  during 
life  by  the  examining  finger,  on  account  of  its  patulous  state  (Fig.  79). 
During  the  fortnight  immediately  preceding  delivery,  however,  a  real 
shortening  or  obliteration  of  the  cervical  cavity  takes  place,  com- 
mencing above,  until  the  cervical  canal  is  merged  into  the  uterine 
cavity ;  but  this,  as  Duncan  has  pointed  out,  seems  to  be  due  to  the 
incipient  uterine  contractions  which  prepare  the  cervix  for  labor. 


1  Researches  in  Obstetrics. 


PREGNANCY. 


143 


There  is,  no  doubt,  an  apparent  shortening  of  the  cervix  always  to 
be  detected  during  pregnancy,  but  this  is  a  fallacious  and  deceptive 
feeling,  due  to  the  softness  of  the  tissue  of  the  cervix,  which  is  exceed- 
ingly characteristic  of  pregnancy,  and  which  to  an  experienced  finger 
affords  one  of  its  best  diagnostic  marks. 


FIG.  79. 


Cervix  from  a  woman  dyiug  in  the  eighth  month  of  pregnancy.    (After  DUNCAN.) 

In  the  non-pregnant  state  the  tissue  of  the  cervix  is  hard,  firm,  and 
inelastic.  When  conception  occurs,  softening  begins  at  the  external 
os,  and  proceeds  gradually  and  slowly  upward  until  it  involves  the 
whole  of  the  cervix.  It  results  from  serous  infiltration  of  the  tissues, 
associated  with  passive  dilatation  of  the  vessels.  By  the  end  of  the 
fourth  month  both  lips  of  the  os  are  thick,  softened,  and  velvety  to 
the  touch,  giving  a  sensation  likened  by  Cazeaux  to  that  produced  by 
pressing  on  a  table  through  a  thick,  soft  cover.  By  the  sixth  month 
at  least  one-half  of  the  cervix  is  thus  altered,  and  by  the  eighth  the 
whole  of  it,  and  so  much  so  that  at  this  time  those  unaccustomed  to 
vaginal  examination  experience  some  difficulty  in  distinguishing  it 
from  the  vaginal  walls.  It  is  this  softening,  then,  which  gives  rise  to 
the  apparent  shortening  of  the  cervix  so  generally  described,  and  it  is 
an  invariable  concomitant  of  pregnancy,  except  in  some  rare  cases  in 
which  there  has  been  antecedent  morbid  induration  and  hypertrophic 
elongation  of  the  cervix.  If,  therefore,  on  examining  a  woman  sup- 
posed to  be  advanced  in  pregnancy,  we  find  the  cervix  to  be  hard  and 
projecting  into  the  vaginal  canal,  we  may  safely  conclude  that  preg- 
nancy does  not  exist.  The  existence  of  softening,  however,  it  must  be 
remembered,  will  not  itself  justify  an  opposite  conclusion,  as  it  may 


144  PREGNANCY. 

be  produced,  to  a  very  considerable  extent,  by  various  pathological 
conditions  of  the  uterus. 

At  the  same  time  that  the  tissue  of  the  cervix  is  softened,  its  cavity 
is  widened,  and  the  external  os  becomes  patulous.  This  change  varies 
considerably  in  primipane  and  multipart.  In  the  former  the  external 
cfe  often  remains  closed  until  the  end  of  pregnancy  ;  but  even  in  them 
it  generally  becomes  more  or  less  patulous  after  the  seventh  mouth, 
and  admits  the  tip  of  the  examining  finger.  In  women  who  have 
borne  children  this  change  is  much  more  marked.  The  lips  of  the 
external  os  are  in  them  generally  fissured  and  irregular,  from  slight 
lacerations  of  its  tissue  in  former  labors.  It  is  also  sufficiently  open 
to  admit  the  tip  of  the  finger,  so  that  in  the  latter  months  of  preg- 
nancy it  is  often  quite  possible  to  touch  the  membranes,  and  through 
them  to  feel  the  presenting  part  of  the  child. 

The  remarkable  increase  in  size  of  the  uterus  during  pregnancy  is, 
as  we  have  seen,  chiefly  to  be  explained  by  the  growth  of  its  struc- 
tures, all  of  which  are  modified  during  gestation.  The  peritoneal 
covering  is  considerably  increased,  so  as  still  to  form  a  complete  cover- 
ing to  the  uterus  when  at  its  largest  size.  William  Hunter  supposed 
that  its  extension  was  effected  rather  by  the  unfolding  of  the  layers  of 
the  broad  ligament  than  by  growth.  That  the  layers  of  the  broad 
ligament  do  unfold  during  gestation,  especially  in  the  early  months,  is 
probable ;  but  this  is  not  sufficient  to  account  for  the  complete  invest- 
ment of  the  uterus,  and  it  is  certain  that  the  peritoneum  grows  pari 
passu  with  the  enlargement  of  the  uterus.  In  addition,  there  is  a 
new  formation  of  fibrous  tissue  between  the  peritoneal  and  the  mus- 
cular coats,  which  affords  strength,  and  diminishes  the  risk  of  lacera- 
tion during  labor. 

The  hypertrophy  of  the  muscular  tissue  of  the  uterus  is,  however, 
the  most  remarkable  of  the  changes  produced  by  pregnancy.  Not 
only  do  the  previously  existing  rudimentary  fibre-cells  become  enor- 
mously increased  in  size — so  as  to  measure,  according  to  Kolliker, 
from  seven  to  eleven  times  their  former  length,  and  from  two  to  five 
times  their  former  breadth  —but  new  unstriped  fibres  are  largely 
developed,  especially  in  the  inner  layers.  These  new  cells  are  chiefly 
found  in  the  first  months  of  pregnancy,  and  their  growth  seems  to  be 
completed  by  the  sixth  month.  The  connective  tissue  between  the 
muscular  layers  is  also  largely  increased  in  amount.  The  weight  of 
the  muscular  tissue  of  the  gravid  uterus  is,  therefore,  much  increased, 
and  it  has  been  estimated  by  Heschl  that  it  weighs  at  term  from  1  to 
1.5  lb.,  that  is,  about  sixteen  times  more  than  in  the  im impregnated 
state.  This  great  development  of  the  muscular  tissue  admits  of  its 
dissection  in  a  way  which  is  quite  impossible  in  the  imimpregnated 
state,  and  the  researches  of  Helie  (p.  62)  enable  us  to  understand  much 
better  than  before  how  the  muscles  forming  the  walls  of  the  gravid 
uterus  act  during  the  expulsion  of  the  child. 

The  changes  in  the  mucous  coat  of  the  uterus  which  result  in  the 
formation  of  the  decidua  have  already  been  discussed  at  length 
elsewhere  (p.  102). 

The  circulatory  apparatus  of  the  uterus  during  pregnancy  has  been 


PREGNANCY.  145 

described  when  the  anatomy  of  the  placenta  was  under  consideration 
(P-  Ho). 

The  lymphatics  are  much  increased  in  size  ;  and  recent  theories  on 
the  production  of  certain  puerperal  diseases  attribute  to  them  a  more 
important  action  than  has  been  commonly  assigned  to  them. 

The  question  of  the  growth  of  the  nerves  has  been  hotly  discussed. 
Robert  Lee  took  the  foremost  place  among,  those  who  maintained  that 
the  nerves  of  the  uterus  share  the  general  growth  of  its  other  con- 
stituent parts.  Dr.  Snow  Beck,  however,  believed  that  they  remain 
of  the  same  size  as  in  the  unimpregnated  state,  and  this  view  is  sup- 
ported by  Hirschfeld,  Robin,  and  other  recent  writers.  Robin  thought 
that  there  is  an  apparent  increase  in  the  size  of  the  nerve-tubes, 
which,  however,  is  really  due  to  increase  in  the  neurilemma.  Kilian 
describes  the  nerves  as  increasing  in  length  but  not  in  thickness, 
while  Schroeder  states  that  they  participate  equally  with  the  lym- 
phatics in  the  enlargement  the  latter  undergo.  Whichever  of  these 
views  may  ultimately  be  found  to  be  correct,  it  is  certain  that  analogy 
would  lead  us  to  expect  an  increase  of  nervous  as  well  as  of  vascular 
supply. 

General  Modifications  in  the  Body  produced  by  Pregnancy. — 
It  is  not  in  the  uterus  alone  that  pregnancy  is  found  to  produce  modi- 
fications of  importance.  There  are  few  of  the  more  important  functions 
of  the  body  which  are  not,  to  a  greater  or  less  extent,  affected ;  to 
some  of  these  it  is  necessary  briefly  to  direct  attention,  inasmuch  as, 
when  carried  to  excess,  they  produce  those  disorders  which  often  com- 
plicate gestation,  and  which  prove  so  distressing  and  even  dangerous 
to  the  patients.  Such  of  them  as  are  apparent  and  may  aid  us  in 
diagnosis  are  discussed  in  the  chapter  Avhich  treats  of  the  signs  and 
symptoms  of  pregnancy  ;  in  this  place  it  is  only  necessary  to  refer  to 
those  which  do  not  properly  fall  into  that  category. 

Amongst  those  which  are  most  constant  and  important  are  the 
alterations  in  the  composition  of  the  blood.  The  opinion  of  the  pro- 
fession on  this  subject  has,  of  late  years,  undergone  a  remarkable 
Change.  Formerly  it  was  universally  believed  that  pregnancy  was, 
as  the  rule,  associated  with  a  condition  analogous  to  plethora,  and 
that  this  explained  many  characteristic  phenomena  of  common  occur- 
rence, such  as  headache,  palpitation,  singing  in  the  ears,  shortness  of 
breath,  and  the  like.  As  a  consequence  it  was  the  habitual  custom, 
not  yet  by  any  means  entirely  abandoned,  to  treat  pregnant  women  on 
an  antiphlogistic  system ;  to  place  them  on  low  diet,  to  administer 
lowering  remedies,  and  very  often  to  practise  venesection,  sometimes 
to  a  surprising  extent.  Thus  it  was  by  no  means  rare  for  women  to 
be  bled  six  or  eight  times  during  the  latter  months,  even  when  no 
definite  symptoms  of  disc-use  existed  ;  and  many  of  the  older  authors 
record  cases  where  depletion  was  practised  every  fortnight  as  a  matter 
of  routine,  and,  when  the  symptoms  were  well  marked,  even  from 
lifty  to  ninety  times  in  the  course  of  a  single  pregnancy. 

Composition  of  the  Blood  in  Pregnancy. — Numerous  careful 
analyses  have  conclusively  proved  that  the  composition  of  the  blood 
during  pregnancy  is  very  generally — perhaps  it  would  not  be  too 


146  PREGNANCY. 

much  to  say  always — profoundly  altered.  To  meet  the  necessities  of 
the  largely  increased  vascular  arrangements  of  the  uterus,  the  total 
amount  of  blood  in  the  system  is  increased.1  It  is  found  to  be  more 
watery,  its  serum  is  deficient  in  albumin,  and  the  amount  of  colored 
globules  is  materially  diminished,  averaging,  according  to  the  analysis 
of  Becquerel  and  Rodier,  111.8  against  127.2  in  the  non-gravid  state. 
At  the  same  time  the  amount  of  fibrin  and  of  extractive  matter  is 
considerably  increased.  The  latter  observation  is  of  peculiar  impor- 
tance, and  it  goes  far  to  explain  the  frequency  of  certain  thrombotie 
affections  observed  in  connection  with  pregnancy  and  delivery ;  this 
hyperinosis  of  the  blood  is  also  considerably  increased  after  labor  by 
the  quantity  of  effete  material  thrown  into  the  mother's  system  at  that 
time,  to  be  got  rid  of  by  her  emunctories.  The  truth  is,  that  the 
blood  of  the  pregnant  woman  is  generally  in  a  state  much  more  nearly 
approaching  the  condition  of  anaemia  than  of  plethora,  and  it  is  certain 
that  most  of  the  phenomena  attributed  to  plethora  may  be  explained 
equally  well  and  better  on  this  view.  These  changes  are  much  more 
strongly  marked  at  the  latter  end  of  pregnancy  than  at  its  commence- 
ment, and  it  is  interesting  to  observe  that  it  is  then  that  the  concomi- 
tant phenomena  alluded  to  are  most  frequently  met  with.  Cazeaux, 
to  whom  we  are  chiefly  indebted  for  insisting  on  the  practical  bearing 
of  these  views,  contends  that  the  pregnant  state  is  essentially  analogous 
to  chlorosis,  and  that  it  should  be  so  treated.  More  recently  the 
accurate  observations  of  Willcocks1  have  shown  that  the  blood  of 
pregnancy  differs  from  that  of  chlorosis  in  the  fact  that  while  in  both 
the  amount  of  haemoglobin  is  lessened,  in  pregnancy  the  individual 
blood-cells  are  not  impoverished  as  they  are  in  chlorosis,  but  simply 
lessened  in  comparative  number,  owing  to  an  increase  in  the  water  of 
the  plasma,  due  to  the  progressive  enlargement  of  the  vascular  area 
during  gestation.  Objection  has  not  unnaturally  been  taken  to 
Cazeaux's  theory,  as  implying  that  a  healthy  and  normal  function  is 
associated  with  a  morbid  state,  and  it  has  been  suggested  that  this  de- 
teriorated state  of  the  blood  may  be  a  wise  provision  of  Nature  instituted 
for  a  purpose  we  are  not  as  yet  able  to  understand.  It  may  certainly 
be  admitted  that  pregnancy,  in  a  perfectly  healthy  state  of  the  system, 
should  not  be  associated  with  phenomena  in  themselves  in  any  degree 
morbid.  It  must  not  be  forgotten,  however,  that  our  patients  are 
seldom — we  might  safely  say  never — in  a  state  that  is  physiologically 
healthy.  The  influence  of  civilization,  climate,  occupation,  diet,  and 
a  thousand  other  disturbing  causes  that,  to  a  greater  or  less  degree, 
are  always  to  be  met  with,  must  not  be  left  out  of  consideration. 
Making  every  allowance,  therefore,  for  the  undoubted  fact  that  preg- 
nancy ought  to  be  a  perfectly  healthy  condition,  it  must  be  conceded, 
I  think,  that  in  the  vast  majority  of  cases  coming  under  our  notice  it 
is  not  entirely  so  ;  and  the  deductions  drawn  by  Cazeaux,  from  the 
numerous  analyses  of  the  blood  of  pregnant  women,  seem  to  point 
strongly  to  the  conclusion  that  the  general  blood-state  is  tending  to 

1  Arch.  f.  Gynak.,  1872,  Bd.  iv.  S.  112. 

2  "Comparative  Observations  on  the  Blood  in  Chlorosis  and  Pregnancy,"  by  Fred.  Willcocks, 
M.D.,  The  Lancet,  Decembers,  18S1. 


PREGNANCY.  147 

poverty  and  anoemia,  and  that  a  depressing  and  antiphlogistic  treatment 
is  distinctly  contra-indicated. 

Modifications  in  certain  Viscera. — Closely  connected  with  the 
altered  condition  of  the  blood  is  the  physiological  hypertrophy  of  the 
heart,  which  is  now  well  known  to  occur  during  pregnancy.  This 
was  first  pointed  out  by  Larcher  in  1828,  and  it  has  been  since  verified 
by  numerous  observers.  It  seems  to  be  constant  and  considerable, 
and  to  be  a  purely  physiological  alteration  intended  to  meet  the 
increased  exigencies  of  the  circulation  which  the  complex  vascular 
arrangements  of  the  gravid  uterus  produce.  The  hypertrophy  is 
limited  to  the  left  ventricle ;  the  right  ventricle,  as  well  as  both 
auricles,  being  unaffected.  Blot  estimates  that  the  whole  weight  of 
the  heart  increases  one-fifth  during  gestation.  The  more  recent  re- 
seaches  of  Lohlein1  render  it  probable  that  the  hypertrophy  is  less 
than  those  authors  have  supposed.  According  to  Duroziez2  the  heart 
remains  enlarged  during  lactation,  but  diminishes  in  size  immediately 
after  delivery  in  women  who  do  not  suckle,  while  in  women  who  have 
borne  many  children  it  remains  permanently  somewhat  larger  than  in 
nullipane.  Similar  increase  in  the  size  of  other  organs  has  been  pointed 
out  by  various  writers,  as,  for  example,  in  the  lymphatics,  the  spleen, 
and  the  liver.  Tarnier  states  that  in  women  who  have  died  after 
delivery,  the  organs  always  show  signs  of  fatty  degeneration.  Accord- 
ing to  Gassner,  the  whole  body  increases  in  weight  during  the  latter 
months  of  pregnancy,  and  this  increase  is  somewhat  beyond  that  which 
can  be  explained  by  the  size  of  the  womb  and  its  contents. 

Formation  of  Osteophytes. — Irregular  bony  deposits  between  the 
skull  and  the  dura  mater,  in  some  cases  so  largely  developed  as  to  line 
the  whole  cranium,  have  been  so  frequently  detected  in  women  who 
have  died  during  parturition  that  they  are  believed  by  some  to  be  a 
normal  production  connected  with  pregnancy.  Dticrest  found  these 
osteophytes  in  more  than  one-third  of  the  cases  in  which  he  performed 
post-mortem  examinations  during  the  puerperal  period.  Rokitansky, 
who  corroborated  the  observation,  believed  this  peculiar  deposit  of 
bony  matter  to  be  a  physiological,  and  not  a  pathological,  condition 
connected  with  pregnancy ;  but  whether  it  be  so,  or  how  it  is  produced, 
lias  not  yet  been  satisfactorily  determined. 

Changes  in  the  Nervous  System. — More  or  less  marked  changes 
connected  with  the  nervous  system  are  generally  observed  in  pregnancy, 
and  sometimes  to  a  very  great  extent.  When  carried  to  excess  they 
produce  some  of  the  most  troublesome  disorders  which  complicate 
gestation,  such  as  alterations  in  the  intellectual  functions,  changes  in 
the  disposition  and  character,  morbid  cravings,  dizziness,  neuralgia, 
syncope,  and  many  others.  They  are  purely  functional  in  their  char- 
acter, and  disappear  rapidly  after  delivery,  and  may  be  best  described 
in  connection  with  the  disorders  of  pregnancy. 

Changes  in  the  Respiratory  Organs. — Respiration  is  often  in- 
terfered with,  from  the  mechanical  results  of  the  pressure  of  the 

1  Zeitschrift  fiirGeburtshUlfe  und  Gynttk.,  1876,  Bd.  i.  S.  482,  "  Ueber  das  Verhalten  des  Herzens 
bei  Sctnvangeren  u.  Wiichuerinnen." 
»  (iiiz.  dos'H.'.i.it.,  1868. 


148  PREGNANCY. 

enlarged  uterus.  The  longitudinal  dimensions  of  the  thorax  are 
lessened  by  the  upward  displacement  of  the  diaphragm,  and  this 
necessarily  leads  to  some  embarrassment  of  the  respiration,  which  is, 
however,  compensated,  to  a  great  extent,  by  an  increase  in  breadth  of 
the  base  of  the  thoracic  cavity. 

Changes  in  the  Liver. — The  liver  has  been  observed  to  show 
certain  changes  in  pregnancy.  Numerous  small  yellow  spots  are  seen 
scattered  through  its  substance,  varying  in  size  from  a  pin's  head  to  a 
millet-seed,  and  these  are  produced  by  fatty  deposits  in  the  hepatic 
cells,  which  De  Sinety  believes  to  be  associated  mainly  with  lactation, 
and  to  disappear  when  that  is  concluded. 

Changes  in  the  Urine. — Certain  changes,  which  are  of  very  con- 
stant occurrence,  in  the  urine  of  pregnant  women  have  attracted  much 
attention,  and  have  been  considered  by  many  writers  to  be  pathogno- 
rnouic.  They  consist  in  the  presence  of  a  peculiar  deposit,  formed 
when  the  urine  has  been  allowed  to  stand  for  some  time,  which  has 
received  the  name  of  kiestein.  Its  presence  was  known  to  the  ancients, 
and  it  was  particularly  mentioned  by  Savonarola  in  the  fifteenth  cen- 
tury, but  it  has  more  especially  been  studied  within  the  last  thirty 
years  by  Eguisier,  Goldiug  Bird,  and  others.  If  the  urine  of  a  preg- 
nant woman  be  allowed  to  stand  in  a  cylindrical  vessel,  exposed  to 
light  and  air,  but  protected  from  dust,  in  a  period  varying  from  two 
to  seven  days,  a  peculiar  flocculeut  sediment,  like  fine  cotton-wool, 
makes  its  appearance  in  the  centre  of  the  fluid,  and  soon  afterward 
rises  to  the  surface  and  forms  a  pellicle,  which  has  been  compared  to 
the  fat  of  cold  mutton-broth.  In  the  course  of  a  few  days  the  scum 
breaks  up  and  falls  to  the  bottom  of  the  vessel.  On  microscopic 
examination  it  is  found  to  be  composed  of  fat  particles,  with  crystals 
of  ammouiaco-magnesium  phosphates  and  phosphate  of  lime,  and  a 
large  quantity  of  vibriones.  These  appearances  are  generally  to  be 
detected  after  the  second  month  of  pregnancy,  and  up  to  the  seventh 
or  eighth  month,  after  which  they  are  rarely  produced.  Regnauld 
explains  their  absence  during  the  latter  mouths  of  gestation  by  the 
presence  in  the  urine,  at  that  time,  of  free  lactic  acid,  which  increases 
its  acidity,  and  prevents  the  decomposition  of  the  urea  into  carbonate 
of  ammonia.  He  believes  that  kiestein  is  produced  by  the  action  of 
free  carbonate  of  ammonia  on  the  phosphate  of  lime  contained  in  the 
urine,  and  that  this  reaction  is  prevented  by  the  excess  of  acid. 

Goldiug  Bird  believed  kiestein  to  be  analogous  to  casein,  to  the 
presence  of  which  he  referred  it,  and  he  states  that  he  has  found  it  in 
twenty-seven  out  of  thirty  cases.  Braxtou  Hicks  so  far  corroborates 
this  view,  and  states  that  the  deposit  of  kiestein  can  be  much  more 
abundantly  produced  if  one  or  two  teaspooufuls  of  rennet  be  added  to 
the  urine,  since  that  substance  has  the  property  of  coagulating  casein. 
Much  less  importance,  however,  is  now  attached  to  the  presence  of 
kiestein  than  formerly,  since  a  precisely  similar  substance  is  sometimes 
found  in  the  urine  of  the  non-pregnant,  especially  in  amemic  women, 
and  even  in  the  urine  of  men.  Parkes  states  that  it  is  not  of  uniform 
composition,  that  it  is  produced  by  the  decomposition  of  urea,  and 
consists  of  the  free  phosphates,  bladder  mucus,  infusoria,  and  vaginal 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  149 

discharges.  Neugebauer  and  Vogel  give  a  similar  account  of  it,  and 
hold  that  it  is  of  no  diagnostic  value.  That  it  is  of  interest  as  indi- 
cating the  changes  going  on  in  connection  with  pregnancy,  is  certain  ; 
but  inasmuch  as  it  is  not  of  invariable  occurrence,  and  may  even  exist 
quite  independently  of  gestation,  it  is  obviously  quite  undeserving  of 
the  extreme  importance  that  has  been  attached  to  it. 

Toward  the  end  of  pregnancy  sugar  may  sometimes  be  detected  in 
the  urine,  and  after  delivery  and  during  lactation  it  exists  in  consider- 
able abundance;  thus,  out  of  thirty-five  cases  tested  in  the  Simpson 
Memorial  Hospital  in  Edinburgh  during  the  puerperium,  it  was  found 
in  all,  the  amount  varying  from  1  to  8  per  cent.1  Kaltenbach  has 
shown  that  this  temporary  glycosuria  is  due  to  the  presence  of  milk- 
sugar  in  the  urine,  and  that  it  ceases  with  the  disappearance  of  milk 
from  the  breasts.2  This  physiological  glycosuria  must  be  carefully 
distinguished  from  true  diabetes,  which  is  a  grave  complication  of 
pregnancy. 

Albumin  is  often  present  during  the  latter  stages  of  pregnancy,  and 
it  may  be  transitory  and  of  comparatively  little  moment,  although  its 
presence  must  always  be  a  cause  of  some  anxiety.  Leyden  believes 
that  it  is  most  often  met  with  in  the  second  half  of  a  first  pregnancy, 
and  it  may  become  chronic,  leading  to  granular  atrophy  of  the  kid- 
neys.3 In  some  cases  it  seems  to  be  the  result  of  catarrhal  conditions 
of  the  bladder,  in  others  it  is  probably  caused  by  undue  arterial 
tension  consequent  on  pregnancy. 


CHAPTER    IY. 

SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

• 

Tx  attempting  to  ascertain  the  presence  or  absence  of  pregnancy,  the 
practitioner  has  before  him  a  problem  which  is  often  beset  with  great 
difficulties,  and  on  the  proper  solution  of  which  the  moral  character 
of  his  patient,  as  well  as  his  own  professional  reputation,  may  depend. 
The  patient  and  her  friends  can  hardly  be  expected  to  appreciate  the 
fact  that  it  is  often  far  from  easy  to  give  a  positive  opinion  on  ^the 
point ;  and  it  is  always  advisable  to  use  much  caution  in  the  examina- 
tion, and  not  to  commit  ourselves  to  a  positive  opinion,  except  on  the 
most  certain  grounds.  This  is  all  the  more  important  because  it  is 
just  in  those  cases  in  which  our  opinion  is  most  frequently  asked  that 
the  statements  of  the  patient  are  of  least  value,  as  she  is  either 

i  Edin.  Med.  Journ.,  vol.  1881-82.  p.  116. 

a  Zeit.  f.  Geburt.  u.  Gyn.,  1879,  Bd.  iv.  p.  161,  "Die  Lactosune  der  Wochnerinnen." 

3  Deutsche  med.  Wocheuschr.,  1886,  No.  9. 


150  PREGNANCY. 

anxious  to  conceal  the  existence  of  pregnancy,  or,  if  desirous  of  an 
affirmative  diagnosis,  unconsciously  colors  her  statements  so  as  to  bias 
the  judgment  of  the  examiner. 

Classification. — Constant  attempts  have  been  made  to  classify  the 
signs  of  pregnancy ;  thus  some  divide  them  into  the  natural  and 
sensible  signs,  others  into  the  presumptive,  the  probable,  and  the  certain. 
The  latter  classification,  which  is  that  adopted  by  Montgomery  in  his 
classical  work  on  the  Signs  and  Symptoms  of  Pregnancy,  is  no  doubt 
the  better  of  the  two,  if  any  be  required.  The  simplest  way  of 
studying  the  subject,  however,  is  the  one,  now  generally  adopted,  of 
considering  the  signs  of  pregnancy  in  the  order  in  which  they  occur, 
and  attaching  to  each  an  estimate  of  its  diagnostic  value. 

Signs  of  a  Fruitful  Conception. — From  the  earliest  ages  authors 
have  thought  that  the  occurrence  of  conception  might  be  ascertained 
by  certain  obscure  signs,  such  as  a  peculiar  appearance  of  the  eyes, 
swelling  of  the  neck,  or  by  unusual  sensations  connected  with  a 
fruitful  intercourse.  All  of  these,  it  need  hardly  be  said,  are  far  too 
uncertain  to  be  of  the  slightest  value.  The  last  is  a  symptom  on  which 
many  married  women  profess  themselves  able  to  depend,  and  one  to 
which  Cazeaux  is  inclined  to  attach  some  importance. 

The  first  appreciable  indication  of  pregnancy  on  which  any  depend- 
ence can  be  placed  is  the  cessation  of  the  customary  menstrual  dis- 
charge, and  it  is  of  great  importance,  as  forming  the  only  reliable 
guide  for  calculating  the  probable  period  of  delivery.  In  women  who 
have  been  previously  perfectly  regular,  in  whom  there  is  no  morbid 
cause  which  is  likely  to  have  produced  suppression,  the  non-appearance 
of  the  catamenia  may  be  taken  as  strong  presumptive  evidence  of  the 
existence  of  pregnancy;  but  it  can  never  be  more  than  this,  unless 
verified  and  strengthened  by  other  signs,  inasmuch  as  there  are  many 
conditions  besides  pregnancy  which  may  lead  to  its  non-appearance. 
Thus  exposure  to  cold,  mental  emotion,  general  debility,  especially 
when  connected  with  incipient  phthisis,  may  all  have  this  effect. 
Mental  impressions  are  peculiarly  liable  to  mislead  in  this  respect. 
It  is  far  from  uncommon  in  newly-married  women  to  find  that  men- 
struation ceases  for  one  or  more  periods,  either  from  the  general  dis- 
turbance of  the  system  connected  with,  the  married  life,  or -from  a 
desire  on  the  part  of  the  patient  to  find  herself  pregnant.  Also  in 
unmarried  women  who  have  subjected  themselves  to  the  risk  of 
impregnation,  mental  emotion  and  alarm  often  produce  the  same 
result. 

A  further  source  of  uncertainty  exists  in  the  fact  that  in  certain 
cases  menstruation  may  go  on  for  one  or  more  periods  after  conception, 
or  even  during  the  whole  pregnancy.  The  latter  occurrence  is  cer- 
tainly of  extreme  rarity,  but  one  or  two  instances  are  recorded  by 
Perfect,  Churchill,  and  other  writers  of  authority,  and  therefore  its 
possibility  must  be  admitted.  The  former  is  much  less  uncommon, 
and  instances  of  it  have  probably  come  under  the  observation  of  most 
practitioners.  The  explanation  is  now  well  understood.  During  the 
early  months  of  gestation,  when  the  ovum  is  not  yet  sufficiently 
advanced  in  growth  to  fill  the  whole  uterine  cavity,  there  is  a  consider- 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  151 

able  space  between  the  decidua  reflexa  which  surrounds  it  and  the 
decidua  vera  lining  the  uterine  cavity.  *  It  is  from  this  free  surface  of 
the  decidua  vera  that  the  periodical  discharge  comes,  and  there  is  not 
only  ample  surface  for  it  to  come  from,  but  a  free  channel  for  its 
escape  through  the  os  uteri.  After  the  third  month  the  decidua  reflexa 
and  the  decidua  vera  blend  together,  and  the  space  between  them  dis- 
appears. Menstruation  after  this  time  is,  therefore,  much  more  diffi- 
cult to  account  for.  It  is  probable  that,  in  many  supposed  cases, 
occasional  losses  of  blood  from  other  sources,  such  as  placenta  praevia, 
an  abraded  cervix  uteri,  or  a  small  polypus,  have  been  mistaken  for 
true  menstruation.  If  the  discharge  really  occurs  periodically  after 
the  third  month,  it  can  only  come  from  the  canal  of  the  cervix.  The 
occurrence,  however,  is  so  rare,  that  if  a  woman  is  menstruating 
regularly  and  normally  who  believes  herself  to  be  more  than  four 
months  advanced  in  pregnancy,  we  are  justified  ipso  facto  in  negativing 
her  supposition.  In  an  unmarried  woman  all  statements  as  to  regu- 
larity of  menstruation  are  absolutely  valueless,  for  in  such  cases 
nothing  is  more  common  than  for  the  patient  to  make  false  statements 
for  the  express  purpose  of  deception. 

Conception  may  unquestionably  occur  when  menstruation  is  nor- 
mally absent.  This  is  far  from  uncommon  in  women  during  lactation, 
when  the  function  is  in  abeyance,  and  who  therefore  have  no  reliable 
data  for  calculating  the  true  period  of  their  delivery.  Authentic  cases 
are  also  recorded  in  which  young  girls  have  conceived  before  men- 
struation is  established,  and  in  which  pregnancy  has  occurred  after 
the  change  of  life. 

Taking  all  these  facts  into  account,  we  can  only  look  upon  the 
cessation  of  menstruation  as  a  fairly  presumptive  sign  of  pregnancy  in 
women  in  whom  there  is  no  clear  reason  to  account  for  it,  but  one 
which  is  undoubtedly  of  great  value  in  assisting  our  diagnosis. 

Shortly  after  conception  various  sympathetic  disturbances  of  the 
system  occur,  and  it  is  only  very  exceptionally  that  these  are  not 
established.  They  are  generally  most  developed  in  women  of  highly 
nervous  temperament ;  and  they  are,  therefore,  most  marked  in  patients 
in  the  upper  classes  of  society,  in  whom  this  class  of  organization  is 
most  common. 

Morning  Sickness. — Amongst  the  most  frequent  of  these  are  vari- 
ous disorders  of  the  gastro-mtestinal  canal.  Nausea  or  vomiting  is  very 
common ;  and  as  it  is  generally  felt  on  first  rising  from  the  recumbent 
position,  it  is  commonly  known  amongst  women  as  the  "  morning 
sickness."  It  sometimes  commences  almost  immediately  after  concep- 
tion, but  more  frequently  not  until  the  second  month,  and  it  rarely 
lasts  after  the  fourth  month.  Generally  there  is  nausea  rather  than 
actual  vomiting.  The  woman  feels  sick  arid  unable  to  eat  her  break- 
fast, and  often  brings  up  some  glairy  fluid.  In  other  cases  she  actually 
vomits;  and  sometimes  the  sickness  is  so  excessive  as  to  resist  all 
treatment,  seriously  to  affect  the  patient's  health,  and  even  imperil 
her  life.  These  grave  forms  of  the  affection  will  require  separate 
consideration. 

Very  different  opinions  have  been  held  as  to  the  cause  of  morning 


152  PREGNANCY. 

sickness.  Dr.  Henry  Bennet  believes  that,  when  at  all  severe,  it  is 
always  associated  with  congestion  and  inflammation  of  the  cervix  uteri. 
Dr.  Graily  Hewitt  maintains  that  it  depends  entirely  on  flexion  of 
the  uterus  producing  irritation  of  the  uterine  nerves  at  the  seat  of  the 
flexion,  and  consequent  sympathetic  vomiting.  This  theory,  when 
broached  at  the  Obstetrical  Society,  was  received  with  little  favor ;  it 
seems  to  me  to  be  sufficiently  disproved  by  the  fact,  which  I  believe 
to  be  certain,  that  more  or  less  nausea  is  a  normal  and  nearly  constant 
phenomenon  in  pregnancy ;  for  it  is  difficult  to  believe  that  nearly 
every  pregnant  woman  has  a  flexed  uterus.  The  generally  received 
explanation  is  probably  the  correct  one,  viz.,  that  nausea,  as  well  as 
other  forms  of  sympathetic  disturbance,  depend  on  the  stretching  ot 
the  uterine  fibres,  by  the  growing  ovum,  and  consequent  irritation  of 
the  uterine  nerves.  It  is,  therefore,  one,  and  only  one,  of  the  numer- 
ous reflex  phenomena  naturally  accompanying  pregnancy.  It  is  an 
old  observation  that  when  the  sickness  of  pregnancy  is  entirely 
absent,  other,  and  generally  more  distressing,  sympathetic  derange- 
ments are  often  met  with,  such  as  a  tendency  to  syncope.  Dr. 
Bedford1  has  laid  especial  stress  on  this  point,  and  maintains  that 
under  such  circumstances  women  are  peculiarly  apt  to  miscarry. 

Other  derangements  of  the  -digestive  functions,  depending  on  the 
same  cause,  are  not  uncommon,  such  as  excessive  or  depraved  appetite, 
the  patient  showing  a  craving  for  strange  and  even  disgusting  articles 
of  diet.  These  cravings  may  be  altogether  irresistible,  and  are  popu- 
larly known  as  "  longings."  Of  a  similar  character  is  the  disturbed 
condition  of  the  bowels  frequently  observed,  leading  to  constipation, 
diarrhoea,  and  excessive  flatulence. 

Certain  glandular  sympathies  may  be  developed,  one  of  the  most 
common  being  an  excessive  secretion  from  the  salivary  glands.  A 
tendency  to  syncope  is  not  unfrequent,  rarely  preceding  to  actual 
fainting,  but  rather  to  that  sort  of  partial  syncope,  unattended  with 
complete  loss  of  consciousness,  which  the  older  authors  used  to  call 
"  leipothymia."  This  often  occurs  in  women  who  show  no  such 
tendency  at  other  times,  and,  when  developed  to  any  extent,  it  forms 
a  very  distressing  accompaniment  of  pregnancy.  Toothache  is  com- 
mon, and  is  not  rarely  associated  with  actual  caries  of  the  teeth. 
When  any  of  these  phenomena  are  carried  to  excess  it  is  more  than 
probable  that  some  morbid  condition  of  the  uterus  exists,  which 
increases  the  local  irritation  producing  them. 

Mental  Peculiarities. — Mental  phenomena  are  very  general.  An 
undue  degree  of  despondency,  utterly  beyond  the  patient's  control,  is 
far  from  uncommon ;  or  a  change  which  renders  the  bright  and  good- 
tempered  woman  fractious  and  irritable ;  or  even  the  more  fortunate, 
but  less  common,  change,  by  which  a  disagreeable  disposition  becomes 
altered  for  the  better. 

All  these  phenomena  of  exalted  nervous  susceptibility  are  but  of 
slight  diagnostic  value.  They  may  be  taken  as  corroborating  more 
certain  signs,  but  nothing  more ;  and  they  are  chiefly  interesting 

1  Diseases  of  Women  and  Children,  p.  551. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  153 

from  their  tendency  to  be  carried  to  excess  and  to  produce  serious 
disorders. 

Certain  changes  in  the  mammae  are  of  early  occurrence,  dependent, 
no  doubt,  on  the  intimate  sympathetic  relations  at  all  times  existing 
between  them  and  the  uterine  organs,  but  chiefly  required  for  the 
purpose  of  preparing  for  the  important  function  of  lactation,  which, 
on  the  termination  of  pregnancy,  they  have  to  perform. 
.  Generally  about  the  second  month  of  pregnancy  the  breasts  become 
increased  in  size,  and  tender.  As  pregnancy  advances  they  become 
much  larger  and  firmer,  the  enlargement  being  caused  by  growth  both 
of  connective  and  glandular  tissue,  and  blue  veins  may  be  seen  cours- 
ing over  them.  The  most  characteristic  changes  are  about  the  nipples 
and  areolae.  The  nipples  become  turgid,  and  are  frequently  covered 


Appearance  of  the  areola  in  pregnancy. 

with  minute  branny  scales,  formed  by  the  desiccation  of  sero-lactescent 
fluid  oozing  from  them.  The  areolse  become  greatly  enlarged  and 
darkened  from  the  deposit  of  pigment  (Fig.  80).  The  extent  and 
degree  of  this  discoloration  vary  much  in  different  women.  In  fair 
women  it  may  be  so  slight  as  to  be  hardly  appreciable ;  while  in  dark 
women  it  is  generally  exceedingly  characteristic,  sometimes  forming  a 
nearly  black  circle  extending  over  a  great  part  of  the  breast.  The  are<  >la 
becomes  moist  as  well  as  dark  in  appearance,  is  somewhat  swollen, 
and  a  number  of  small  tubercles  are  developed  upon  it,  forming  a 
circle  of  projections  round  the  nipple.  These  tubercles  are  described 
by  Montgomery  as  being  intimately  connected  with  the  lactiferous 
ducts,  some  of  which  may  occasionally  be  traced  into  them  and  seem 
to  open  on  their  summits.  As  pregnancy  advances  they  increase  in 
size  and  number.  During  the  latter  months  what  has  been  called 


154  PREGNANCY. 

"the  secondary  areola"  is  produced,  and  when  well  marked  presents 
a  very  characteristic  appearance.  It  consists  of  a  number  of  minute 
discolored  spots  all  round  the  outer  margin  of  the  areola  where  the 
pigmentation  is  fainter,  and  which  are  generally  described  as  resem- 
bling spots  from  which  the  color  has  been  discharged  by  a  shower  of 
water-drops.  This  change,  like  the  darkening  of  the  primary  areola, 
is  more  marked  in  brunettes.  At  this  period,  especially  in  women 
whose  skin  is  of  fine  texture,  wrhitish  silvery  streaks  are  often  seen  on 
the  breasts.  They  are  produced  by  the  stretching  of  the  cutis  vera, 
and  are  permanent. 

By  pressure  on  the  breasts  a  small  drop  of  serous-looking  fluid  can 
very  generally  be  forced  out  from  the  nipple,  often  as  early  as  the 
third  month,  and  on  microscopic  examination  milk  and  colostrum 
globules  can  be  seen  in  it. 

The  diagnostic  value  of  these  mammary  changes  has  been  variously 
estimated.  When  well  marked  they  are  considered  by  Montgomery 
to  be  certain  signs  of  pregnancy.  To  this  statement,  however,  some 
important  limitations  must  be  made.  In  women  who  have  never 
borne  children  they,  no  doubt,  are  so ;  for,  although  various  uterine 
and  ovarian  diseases  produce  some  darkening  of  the  areola,  they  cer- 
tainly never  produce  the  well-marked  changes  above  described.  In 
multipart,  however,  the  areolse  often  remain  permanently  darkened, 
and  in  them  these  signs  are  much  less  reliable.  In  first  pregnancies 
the  presence  of  milk  in  the  breasts  may  be  considered  an  almost  cer- 
tain sign,  and  it  is  one  which  I  have  rarely  failed  to  detect  even  from 
a  comparatively  early  period.  It  is  true  that  there  are  authenticated 
instances  of  non-pregnant  wromen  having  an  abundant  secretion  of 
milk  established  from  mammary  irritation.  Thus  Baudelocque  pre- 
sented to  the  Academy  of  Surgery  of  Paris  a  young  girl,  eight  years 
of  age,  who  had  nursed  her  little  brother  for  more  than  a  mouth. 
Dr.  Tanner  states — I  do  not  know  on  what  authority — that  "  it  is  not 
uncommon  in  Western  Africa  for  young  girls  who  have  never  been 
pregnant  to  regularly  employ  themselves  in  nursing  the  children  of 
others,  the  mammae  being  excited  to  action  by  the  application  of  the 
juice  of  one  of  the  Euphorbiaceae."  Lacteal  secretion  has  even  been 
noticed  in  the  male  breast.  But  these  exceptions  to  the  general  rule 
are  so  uncommon  as  merely  to  deserve  mention  as  curiosities ;  and  I 
have  hardly  ever  been  deceived  in  diagnosing  a  first  pregnancy  from 
the  presence  of  even  the  minutest  quantity  of  lacteal  secretion  in  the 
breasts,  although  even  then  other  corroborative  signs  should  always 
be  sought  for.  In  multiparae  the  presence  of  milk  is  by  no  means  so 
valuable,  for  it  is  common  for  milk  to  remain  in  the  mammae  long 
after  the  cessation  of  lactation,  even  for  several  years.  Tyler  Smith 
correctly  says  that  "suppression  of  the  milk  in  persons  who  are 
nursing  and  liable  to  impregnation  is  a  more  valuable  sign  of  preg- 
nancy than  the  converse  condition."  This  is  an  observation  I  have 
frequently  corroborated. 

As  a  diagnostic  sign,  therefore,  the  mammary  appearances  are  of 
great  importance  in  prirniparse,  and  when  well  marked  they  are  seldom 
likely  to  deceive.  They  are  specially  important  when  we  suspect 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  155 

pregnancy  hi  the  unmarried,  as  we  ean  easily  make  an  excuse  to  look 
at  the  breast  without  explaining  to  the  patient  the  reason ;  and  a 
single  glance,  especially  if  the  patient  be  dark-complexioned,  may 
so  far  strengthen  our  suspicion  as  to  justify  a  more  thorough  examina- 
tion. In  married  multipart  they  are  less  to  be  depended  upon. 

In  connection  with  this  subject  may  be  mentioned  various  irregular 
deposits  of  pigment  which  are  frequently  observed.  The  most  com- 
mon is  a  dark-brownish  or  yellowish  line  starting  from  the  pubes  and 
running  up  the  centre  of  the  abdomen,  sometimes  as  far  as  the  um- 
bilicus only,  at  others  forming  an  irregular  ring  around  the  umbilicus, 
and  reaching  to  the  epigastrium.  It  is,  however,  of  very  uncertain 
occurrence,  being  well  marked  in  some  women,  while  in  others  it  is 
entirely  absent.  [']  Patches  of  darkened  skin  are  often  observed  about 
the  face,  chiefly  on  the  forehead,  and  this  bronzing  sometimes  gives  a 
very  peculiar  appearance.  Joulin  states  that  it  only  occurs  on  parts 
of  the  face  exposed  to  the  sun,  and  that  it  is  therefore  most  fre- 
quently observed  in  women  of  the  lower  orders  who  are  freely  exposed 
to  atmospheric  influences.  These  pigmentary  changes  are  of  small 
diagnostic  value,  and  may  continue  for  a  considerable  time  after  de- 
livery." 

The  progressive  enlargement  of  the  abdomen,  and  the  size  of  the 
gravid  uterus  at  various  periods  of  pregnancy,  as  well  as  the  method 
of  examination  by  means  of  abdominal  palpation,  have  already  been 
described  (pp.  129  and  137-140). 

Foetal  Movements. — We  will  now  consider  the  well-known  phe- 
nomena produced  by  the  movements  of  the  foetus  in  utero,  which  are 
so  familiar  to  all  pregnant  women.  These,  no  doubt,  take  place  from 
the  earliest  period  of  foetal  life  at  which  the  muscular  tissue  of  the 
foetus  is  sufficiently  developed  to  admit  of  contraction,  but  they  are 
not  felt  by  the  mother  until  somewhere  about  the  sixteenth  week  of 
utero-gestation,  the  precise  period  at  which  they  are  perceived  varying 
considerably  in  different  cases.  The  error  of  the  law  on  this  subject, 
which  supposes  the  child  not  to  be  alive,  or  "  quick,"  until  the  mother 
feels  its  movements,  is  well  known,  and  has  frequently  been  protested 
against  by  the  medical  profession.  The  so-called  quickening — which 
certainly  is  felt  very  suddenly  by  some  women — is  believed  to  depend 
on  the  rising  of  the  uterine  tumor  sufficiently  high  to  permit  of  the 
impulse  of  the  foetus  being  transmitted  to  the  maternal  abdominal  walls, 
through  the  sensory  nerves  of  which  its  movements  become  appreci- 
able. The  sensation  is  generally  described  as  being  a  feeble  flutter- 
ing, which,  when  first  felt,  not  imfrequently  causes  unpleasant 
nervous  sensations.  As  the  uterus  enlarges,  the  movements  become 
more  and  more  distinct,  and  generally  consist  of  a  series  of  sharp 
blows  or  kicks,  sometimes  quite  appreciable  to  the  naked  eye,  and 
causing  distinct  projections  of  the  abdominal  walls.  Their  force  and 
frequency  will  also  vary  during  pregnancy  according  to  circumstances. 
At  times  they  are  very  frequent  and  distressing ;  at  others,  the  foetus 

F1  The  color-line  is  particularly  well  marked  in  the  African  race,  and  is  very  black  in  the  full- 
blooded  negro.  In  tumor  cases,  there  is  often  a  well-defined  line  over  the  linea  alba,  which  is 
sometimes  quite  crooked,  and  of  an  orange  hue.— ED.  J 


15(3  PREGNANCY 

seems  to  be  comparatively  quiet,  and  they  may  even  not  be  felt  for 
several  days  in  succession,  and  thus  unnecessary  fears  as  to  death 
of  the  fetus  often  arise.  The  state  of  the  mother's  health  has  an 
undoubted  influence  upon  them.  They  are  said  to  increase  in  force 
after  a  prolonged  abstinence  from  food,  or  in  certain  positions  of  the 
body.  It  is  certain  that  causes  interfering  with  the  vitality  of  the 
foetus  often  produce  very  irregular  and  tumultuous  movements.  They 
can  be  very  readily  felt  by  the  accoucheur  on  palpating  the  abdomen, 
and  sometimes,  in  the  latter  months,  so  distinctly  as  to  leave  no  doubt 
as  to  the  existence  of  pregnancy.  They  can  also  generally  be  induced 
by  placing  one  hand  on  each  side  of  the  abdomen  and  applying 
gentle  pressure,  which  will  induce  foetal  motion  that  can  be  easily 
appreciated. 

As  a  diagnostic  sign  the  existence  of  fcetal  movements  has  always 
held  a  high  place,  but  care  should  be  taken  in  relying  on  it.  It  is 
certain  that  women  are  themselves  very  often  in  error,  and  fancy  they 
feel  the  movements  of  a  foetus  when  none  exists,  being  probably 
deceived  by  irregular  contractions  of  the  abdominal  muscles,  or  by 
flatus  within  the  bowels.  They  may  even  involuntarily  produce  such 
intra-abdominal  movements  as  may  readily  deceive  the  practitioner. 
Of  course,  in  advanced  pregnancy,  when  the  fcetal  movements  are  so 
marked  as  to  be  seen  as  well  as  felt,  a  mistake  is  hardly  possible,  and 
they  then  constitute  a  certain  sign.  But  in  such  cases  there  is  an 
abundance  of  other  indications  and  little  room  for  doubt.  In  ques- 
tionable cases,  and  at  an  early  period  of  pregnancy,  the  fact  that  move- 
ments are  not  felt  must  not  be  taken  as  a  proof  of  the  non-existence 
of  pregnancy,  for  they  may  be  so  feeble  as  not  to  be  perceptible,  or 
they  may  be  absent  for  a  considerable  period. 

Braxton  Hicks1  has  directed  attention  to  the  value,  from  a  diagnostic 
point  of  view,  of  intermittent  contractions  of  the  uterus  during  preg- 
nancy. After  the  uterus  is  sufficiently  large  to  be  felt  by  palpation, 
if  the  hand  be  placed  over  it,  and  it  be  grasped  for  a  time  without 
using  any  friction  or  pressure,  it  will  be  observed  to  distinctly  harden 
in  a  manner  that  is  quite  characteristic.  This  intermittent  contraction 
occurs  every  five  or  ten  minutes,  sometimes  oftener,  rarely  at  longer 
intervals.  The  fact  that  the  uterus  does  contract  in  this  way  had  been 
previously  described,  more  especially  by  Tyler  Smith,  who  ascribed  it 
to  peristaltic  action.  But  it  is  certain  that  no  one,  before  Dr.  Hicks, 
had  pointed  out  the  fact  that  such  contractions  are  constant  and 
normal  concomitants  of  pregnancy,  continuing  during  the  whole 
period  of  utero-gestation,  and  forming  a  ready  and  reliable  means  of 
distinguishing  the  uterine  tumor  from  other  abdominal  enlargements. 
Since  reading  Dr.  Hicks's  paper  I  have  paid  considerable  attention  to 
this  sign,  which  I  have  never  failed  to  detect,  even  in  the  retroverted 
gravid  uterus  contained  entirely  in  the  pelvic  cavity,  and  I  am  dis- 
posed entirely  to  agree  with  him  as  to  its  great  value  in  diagnosis.  If 
the  hand  be  kept  steadily  on  the  uterus,  its  alternate  hardening  and 
relaxation  can  be  appreciated  with  the  greatest  ease.  The  advantages 

1  Obst.  Trans.,  1872,  vol.  xiii.  p.  216. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  157 

which  this  sign  has  over  the  foetal  movements  are  that  it  is  constant, 
that  it  is  not  liable  to  be  simulated  by  anything  else,  and  that  it  is 
independent  of  the  life  of  the  child,  being  equally  appreciable  when 
the  uterus  contains  a  degenerated  ovum  or  dead  foetus.  The  only  con- 
dition likely  to  give  rise  to  error  is  an  enlargement  of  the  uterus  in 
consequence  of  contents  other  than  the  results  of  conception,  such  as 
retained  menses,  or  a  polypus.  The  history  of  such  cases— which  are, 
moreover,  of  extreme  rarity — would  easily  prevent  any  mistake.  As 
a  corroborative  sign  of  pregnancy,  therefore,  I  should  give  these  in- 
termittent contractions  a  high  place.  [L] 

The  vaginal  signs  of  pregnancy  are  of  considerable  importance 
in  diagnosis.  They  are  chiefly  the  changes  which  may  be  detected  in 
the  cervix,  and  the  so-called  ballottement,  which  depends  on  the  mobility 
of  the  foetus  in  the  liquor  amnii. 

Softening  of  the  Cervix. — The  alterations  in  the  density  and 
apparent  length  of  the  cervix  have  been  already  described  (p.  142). 
When  pregnancy  has  advanced  beyond  the  fifth  month  the  peculiar 
velvety  softness  of  the  cervix  is  very  characteristic,  and  affords  a  strong 
corroborative  sign,  but  one  which  it  would  be  unsafe  to  rely  on  by 
itself,  inasmuch  as  very  similar  alterations  may  be  produced  by  various 
causes.  When,  however,  in  a  supposed  case  of  pregnancy  advanced 
beyond  the  period  indicated,  the  cervix  is  found  to  be  elongated,  dense, 
and  projecting  into  the  vaginal  canal,  the  non-existence  of  pregnancy 
may  be  safely  inferred.  Therefore  the  negative  value  of  this  sign  is 
of  more  importance  than  the  positive.  In  connection  with  this  may 
be  mentioned  a  sign  of  pregnancy  to  which  attention  has  recently 
been  drawn  by  Hegar.2  It  consists  in  a  peculiar  elasticity  of  the 
lower  segments  of  the  uterus,  made  out  by  vaginal  or  rectal  examina- 
tion. It  may  serve  to  differentiate  the  pregnant  uterus  from  certain 
uterine  enlargements  due  to  tumor  in  cases  in  which  the  diagnosis  is 
doubtful. 

Ballottement,  when  distinctly  made  out,  Js  a  very  valuable  indica- 
tion of  pregnancy.  It  consists  in  the  displacement,  by  the  examining 
finger,  of  the  foetus,  which  floats  up  in  the  liquor  amnii,  and  falls  back 
again  on  the  tip  of  the  finger  with  a  slight  tap  which  is  exceedingly 
characteristic. 

In  order  to  practise  it  most  easily,  the  patient  is  placed  on  a  couch 
or  bed  in  a  position  midway  between  sitting  and  lying,  by  which  the 
vertical  diameter  of  the  uterine  cavity  is  brought  into  correspondence 
with  that  of  the  pelvis.  Two  fingers  of  the  right  hand  are  then  passed 
high  up  into  the  vagina  in  front  of  the  cervix.  The  uterus  being  now 
steadied  from  without  by  the  left  hand,  the  intra- vaginal  fingers  press 
the  uterine  wall  suddenly  upward,  when,  if  pregnancy  exist,  the  foetus 
is  displaced,  and  in  a  moment  falls  back  again,  imparting  a  distinct 
impulse  to  the  fingers.  When  easily  appreciable  it  may  be  considered 
as  ;i  certain  sign,  for  although  an  anteflexed  fundus,  or  a  calculus  in 

f1  In  a  case  where  ectopic  pregnancy  had  been  long  suspected  in  this  city,  the  movements  here 
noted  deckled  the  gestation  to  be  uterine,  and  the  woman  delivered  herself.  She  had  a  bind  uterus, 
•with  one  half  empty,  and  admitting  a  sound  four  and  a  half  inches.— Eu.] 

8  Centralblatt  fur  Gyniik.,  1887,  Bd.  xi.  S.  805. 


158  PREGNANCY. 

the  bladder,  may  give  rise  to  somewhat  similar  sensations,  the  absence 
of  other  indications  of  pregnancy  would  really  prevent  error.  Bal- 
lottement  is  practised  between  the  fourth  and  seventh  months.  Before 
the  former  time  the  foetus  is  too  small,  while  at  a  later  period  it  is 
relatively  too  large,  and  can  no  longer  be  easily  made  to  rise  upward 
in  the  surrounding  liquor  amuii.  The  absence  of  ballottement  must 
not  be  taken  as  proving  the  non-existence  of  pregnancy,  for  it  may  be 
inappreciable  from  a  variety  of  causes,  such  as  abnormal  presentations, 
or  the  implantation  of  the  placenta  upon  the  cervix  uteri. 

Vaginal  Pulsation. — There  are  also  some  other  vaginal  signs  of 
pregnancy  of  secondary  consequence.  Amongst  these  is  the  vaginal 
pulsation  pointed  out  by  Osiander  resulting  from  the  enlargement  of 
the  vaginal  arteries,  which  may  sometimes  be  felt  beating  at  an  early 
period.  Often  this  pulsation  is  very  distinct,  at  other  times  it  cannot 
be  felt  at  all,  and  it  is  altogether  unreliable,  as  a  similar  pulsation  may 
be  felt  in  various  uterine  diseases. 

Uterine  Fluctuation. — Dr.  Rasch  has  drawn  attention  to  a  pre- 
viously undescribed  sign  which  he  believes  to  be  of  importance  in  the 
diagnosis  of  early  pregnancy.1  It  consists  in  the  detection  of  fluctua- 
tion, through  the  anterior  uterine  wall,  depending  on  the  presence  of 
the  liquor  amnii.  In  order  to  make  this  out,  two  fingers  of  -the  right 
hand  must  be  used,  as  in  ballottement,  while  the  uterus  is  steadied 
through  the  abdomen.  Dr.  Rasch  states  that  by  this  means  the  en- 
larged uterus  in  pregnancy  can  easily  be  distinguished  from  enlarge- 
ment depending  on  other  causes,  and  that  fluctuation  can  always  be 
felt  as  early  as  the  second  month.  If  it  is  associated  with  suppressed 
menstruation  and  darkened  areolse,  he  considers  it  a  certain  sign.  In 
order  to  detect  it,  however,  considerable  experience  in  making  vaginal 
examinations  is  essential,  and  it  can  hardly  be  depended  on  for  gen- 
eral use. 

A  peculiar  deep  violet  hue  of  the  vaginal  mucous  membrane  Mas 
relied  on  by  Jacquemin2-  and  Kliige  as  aifording  a  readily  observed 
indication  of  pregnancy.  In  most  cases  it  is  well  marked  ;  sometimes, 
indeed,  the  change  of  color  is  very  intense,  and  it  evidently  depends 
on  the  congestion  produced  by  pressure  of  the  enlarged  uterus.  Chad- 
wick,  of  Boston,  has  recently  reinvestigated  this  sign,  and  attributes 
to  it  a  high  diagnostic  value.3  It  has  been  generally  stated  to  be 
unreliable,  as  a  similar  discoloration  is  said  to  be  produced  by  the 
pressure  of  large  uterine  fibroids.  This,  however,  Chad  wick  declares 
is  not  the  case. 

Auscultatory  Signs  of  Pregnancy. — By  far  the  most  important 
signs  are  those  which  can  be  detected  by  abdominal  auscultation,  and 
one  of  these  —  the  hearing  of  the  foetal  heart-sounds  —  forms  the 
only  sign  which  per  se,  and  in  the  absence  of  all  others,  is  perfectly 
reliable. 

1  Brit.  Med.  Journ.,  1873,  vol.  ii.  p.  261. 

2  The  credit  of  first  drawing  attention  to  this  sign  of  pregnancy  is  generally  given  to  Jacquemier, 
a  distinguished  French  obstetrician,  who  wrote  a  work  on  Midwifery.    It  is  due,  however,  to 
Jacquemin,  medecin  en  chef  de  la  prison  de  Mazas.  and  is.  in  fact,  attributed  to  him  in  Jacquemier'a 
work  (Manuel  des  Accoucheroents,  par  J.  Jacquemier.  Paris,  1846.  vol.  i.  p.  215). 

a  Transactions  of  the  American  Gynecological  Society,  1SSC,  vol.  ii.  p.  399. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  159 

The  fact  that  the  sounds  of  the  foetal  heart  are  audible  during  ad- 
vanced pregnancy  was  first  pointed  out  by  Mayor,  of  Geneva,  in  1818, 
and  the  main  facts  in  connection  with  fcetal  auscultation  were  subse- 
quently worked  out  by  Kergaradec,  Xaegele,  Evory  Kennedy,  and 
other  observers.  The  pulsations  first  become  audible,  as  a  rule,  in  the 
course  of  the  fifth  month,  or  about  the  middle  of  the  fourth  month. 
In  exceptional  circumstances,  and  by  practised  observers,  they  have 
been  heard  earlier.  Depaul  believes  that  he  detected  them  as  early  as 
the  eleventh  week,  and  Routh  has  also  detected  them  at  an  earlier 
period  by  vaginal  stethoscopy,  which,  however,  for  obvious  reasons, 
cannot  be  ordinarily  employed.  Naegele  never  heard  them  before  the 
eighteenth  week,  more  generally  at  the  end  of  the  twentieth,  and  for 
practical  purposes  the  pregnancy  must  be  advanced  to  the  fifth  month 
before  we  can  reasonably  expect  to  detect  them.  From  this  period  up 
to  term  they  can  almost  always  be  heard  to  a  certainty,  if  not  at  the 
first  attempt,  at  least  afterward,  if  we  have  the  opportunity  of  making 
repeated  examinations.  Accidental  circumstances,  such  as  the  presence 
of  an  unusual  amount  of  flatus  in  the  intestines,  may  deaden  the 
sounds  for  a  time,  but  not  permanently.  Depaul  only  failed  to  hear 
them  in  8  cases  out  of  906  examined  during  the  last  three  months  of 
pregnancy;  and  out  of  180  cases  which  Dr.  Anderson,  of  Glasgow, 
carefully  examined,  he  only  failed  in  12,  and  in  each  of  these  the  child 
was  stillborn.  They,  therefore,  form  not  only  a  most  certain  indication 
of  pregnancy,  but  of  the  life  of  the  foetus  also. 

The  sound  has  always  been  likened  to  the  double  tic-tac  of  a  watch 
hoard  through  a  pillow,  which  it  closely  resembles.  It  consists  of  two 
beats,  separated  by  a  short  interval,  the  first  being  the  loudest  and 
most  distinct,  the  second  being  sometimes  inaudible.  The  rapidity  of 
the  fcetal  pulsations  forms  an  important  means  of  distinguishing  them 
from  transmitted  maternal  pulsations  with  which  they  might  be  con- 
founded. Their  average  number  is  stated  by  Slater,  who  made  numer- 
ous observations  on  this  point,  to  be  132,  but  sometimes  they  reach  as 
high  as  140,  and  sometimes  as  low  as  120.  It  will  thus  be  seen  that 
the  pulsations  are  always  much  more  rapid  than  those  of  the  mother's 
heart,  unless,  indeed,  the  latter  be  unduly  accelerated  by  transient 
mental  emotion  or  disease.  To  avoid  mistakes,  whenever  the  fcetal 
heart  is  heard  its  rate  of  pulsation  should  be  carefully  counted,  and 
compared  with  that  of  the  mother's  pulse ;  if  the  rate  differ,  we  may 
be  sure  that  no  error  has  been  made.  The  rapidity  of  the  foetal  pulsa- 
tions remains,  as  a  rule,  the  same  during  the  whole  period  of  preg- 
nancy, while  their  intensity  gradually  increases.  They  may,  however, 
be  temporarily  increased  or  diminished  in  frequency  by  disturbing 
causes,  such  as  the  pressure  of  the  stethoscope,  which,  exciting 
tumultuous  movements  of  the  foetus,  may  induce  greatly  increas«l 
frequency  of  its  heart-beats.  So  also  they  may  be  greatly  modified 
during  labor,  after  the  escape  of  the  liquor  amnii,  when  the  contrac- 
tions of  the  uterus  have  a  very  distinct  influence  on  the  foetus.  An 
acceleration  or  irregularity  of  the  pulsations,  made  out  in  the  course 
of  a  prolonged  labor,  may  thus  be  of  great  practical  importance,  by 
indicating  the  necessity  for  prompt  interference.  Similar  alterations, 


160  PREGNANCY. 

associated  with  tumultuous  and  unusual  foetal  movements  felt  by  the 
mother  toward  the  end  of  pregnancy,  may  point  to  danger  to  the  life 
of  the  foetus  during  the  latter  months,  and  may  even  justify  the  induc- 
tion of  premature  labor.  This  is  especially  the  case  in  women  who 
have  previously  given  birth  to  a  succession  of  dead  children  owing 
to  disease  of  the  placenta,  and,  in  them,  careful  and  frequently 
repeated  auscultations  may  warn  us  of  the  impending  danger. 

The  rapidity  of  the  foetal  heart  has  been  supposed  by  some  to  afford 
a  means  of  determining  the  sex  of  the  child  before  birth.  Franken- 
hauser,  Avho  first  directed  attention  to  this  point,  is  of  opinion  that  the 
average  rate  of  pulsations  of  the  heart  is  considerably  less  in  male  than 
in  female  children,  averaging  124  in  the  minute  in  the  formci\as 
against  144  in  the  latter.  Steinbach  makes  the  difference  somewhat 
less,  viz.,  131  for  males  and  138  for  females.  He  predicted  the  sex 
correctly  by  this  means  in  45  out  of  57  cases,  while  Frankenhauser 
was  correct  in  the  whole  50  cases  which  he  specially  examined  with 
reference  to  the  point.  Dr.  Hutton,  of  New  York,1  was  also  correct 
in  7  cases  which  he  fixed  on  for  trial.  Devilliers  found,  the  difference 
in  the  sexes  to  be  the  same  as  Steinbach  ;  he  attributes  it,  however, 
to  the  size  and  weight  rather  than  to  the  sex  of  the  child,  and  believes 
the  pulsations  to  be  least  numerous  in  large  and  well-developed  chil- 
dren. As  male  children  are  usually  larger  than  female,  he  thus 
explains  the  relatively  less  frequent  pulsations  of  their  hearts.  Dr. 
Cummiug,  of  Edinburgh,  also  believes  that  the  weight  of  the  child  has 
considerable  influence  on  the  frequency  of  its  cardiac  pulsations,  so 
that  a  large  female  child  may  have  a  slower  pulse  than  a  small  male.2 
The  point,  however,  is  more  curious  than  practical,  and  the  rapidity 
of  the  pulsations  certainly  would  not  justify  any  positive  prediction 
on  the  subject.  Circumstances  influencing  the  maternal  circulation 
seem  to  have  no  influence  on  that  of  the  foetus. 

The  foetal  heart-sounds  are  generally  propagated  best  by  the  back 
of  the  child,  and  are,  therefore,  most  easily  audible  when  this  is  in 
contact  with  the  anterior  wall  of  the  uterus,  as  is  the  case  in  the  large 
majority  of  pregnancies.  When  the  child  is  placed  in  the  dorso- 
posterior  position,  the  sounds  have  to  traverse  a  larger  amount  of  the 
liquor  amnii,  and  are  further  modified  by  the  interposition  of  the  foetal 
limbs.  They  are,  therefore,  less  easily  heard  in  such  cases,  but  even 
in  them  they  can  almost  always  be  made  out.  As  the  foetus  most 
frequently  lies  with  the  occiput  over  the  brim  of  the  pelvis,  and  the 
back  of  the  child  toward  the  left  side  of  the  mother,  the  heart-sounds 
are  usually  most  distinctly  audible  at  a  point  midway  between  the 
umbilicus  and  the  left  anterior  superior  spine  of  the  ilium.  In  the 
next  most  common  position,  in  which  the  back  of  the  child  lies  to 
the  right  lumbar  region  of  the  mother,  they  are  generally  heard  at  a 
corresponding  point  at  the  right  side,  but  in  this  case  they  are  fre- 
quently more  readily  made  out  in  the  right  flank,  being  then  trans- 
mitted through  the  thorax  of  the  child,  which  is  in  contact  with  the 
side  of  the  uterus.  In  breech  cases,  on  the  other  hand,  the  heart- 

1  New  York  Mecl.  Journ.,  1872,  vol.  xvi.  p.  68. 
*  Edin.  Med.  Journ.,  vol.  1375-76,  pp.  230,  317,  418. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  161 

sounds  are  generally  heard  most  distinctly  above  the  umbilicus,  and 
either  to  the  right  or  left,  according  to  the  side  toward  which  the  back 
of  the  child  is  placed.  It  will  thus  be  seen  that  the  place  at  which 
the  foetal  heart-sounds  are  heard  varies  with  the  position  of  the  foetus ; 
and  this,  when  combined  with  the  information  derived  from  palpation, 
affords  a  ready  means  of  ascertaining  the  presentation  of  the  child 
before  labor.  The  sounds  are  only  audible  over  a  limited  space, 
about  two  or  three  inches  in  diameter ;  therefore,  if  we  fail  to  detect 
them  in  one  place,  a  careful  exploration  of  the  whole  uterine  tumor  is 
necessary  before  we  are  satisfied  that  they  cannot  be  heard. 

The  only  mistake  that  is  likely  to  be  made  is  taking  the  maternal 
pulsations,  transmitted  through  the  uterine  tumor,  for  those  of  the 
foetal  heart.  A  little  care  will  easily  prevent  this  error,  and  the  fre- 
quency of  the  mother's  pulse  should  always  be  ascertained  before 
counting  the  supposed  foetal  pulsations.  If  these  are  found  to  be  1 20 
or  more,  while  the  mother's  pulse  is  only  70  or  80,  no  mistake  is 
possible.  If  the  latter  is  abnormally  quickened  greater  care  may  be 
necessary,  but  even  then  the  rate  of  pulsation  of  each  will  be  dis- 
similar. Braxton  Hicks1  has  pointed  out  that  in  tedious  labor,  when 
the  muscular  powers  of  the  mother  are  exhausted,  the  muscular  su- 
surrus  may  produce  a  sound  closely  resembling  the  foetal  pulsation ; 
but  error  from  this  source  is  obviously  very  improbable. 

In  listening  for  the  foetal  heart-sounds  the  patient  should  be  placed 
on  her  back,  with  the  shoulders  elevated  and  the  knees  flexed.  The 
surface  of  the  abdomen  should  be  uncovered,  and  an  ordinary  stetho- 
scope employed,  the  end  of  which  must  be  pressed  firmly  on  the 
tumor,  so  as  to  depress  the  abdominal  Avails.  The  most  absolute  still- 
ness is  necessary,  as  it  is  often  far  from  easy  to  hear  the  sounds. 
Sometimes,  after  failing  with  the  ordinary  stethoscope,  I  have  suc- 
ceeded with  the  binaural,  which  remarkably  intensifies  them.  When 
once  heard  they  are  most  easily  counted  during  a  space  of  five  seconds, 
as,  on  account  of  their  frequency,  it  is  not  always  possible  to  follow 
them  over  a  longer  period. 

When  the  foetal  heart-sounds  are  heard  distinctly,  pregnancy  may 
be  absolutely  and  certainly  diagnosed.  The  fact  that  we  do  not  hear 
them  does  not,  however,  preclude  the  possibility  of  gestation,  for  the 
foetus  may  be  dead,  or  the  sounds  temporarily  inaudible. 

Other  Sounds  heard  in  Pregnancy. — There  are  some  other  sounds 
heard  in  auscultation  which  are  of  very  secondary  diagnostic  value. 
One  of  these  is  the  so-called  umbilical  or  funic  souffle,  which  was  first 
pointed  out  by  Evory  Kennedy.  It  consists  of  a  single  blowing 
murmur,  synchronous  with  the  foetal  heart-sounds,  and  most  distinctly 
heard  in  the  immediate  vicinity  of  the  point  where  these  are  most 
audible.  Most  authors  believe  it  to  be  produced  by  pressure  on  the 
cord,  either  when  it  is  placed  between  a  hard  part  of  the  foetus  and 
the  uterine  walls,  or  is  twisted  around  the  child's  neck.  Schroeder 
and  Hecker  detected  it  in  fourteen  or  fifteen  per  cent,  of  all  cases,  and 
the  latter  believed  it  to  be  caused  by  flexure  of  the  first  portion  of  the 

i  Obst.  Trans.,  1874,  vol.  XV.  p.  187. 
11 


162  PEEGNANCY. 

cord  near  the  umbilicus.  For  practical  purposes  it  is  quite  valueless, 
and  need  only  be  mentioned  as  a  phenomenon  which  an  experienced 
auscultator  may  occasionally  detect. 

The  uterine  souffle  is  a  peculiar  single  whizzing  murmur  which  is 
almost  always  audible  on  auscultation.  It  varies  very  remarkably  in 
character  and  position.  Sometimes  it  is  a  gentle  blowing  or  even 
musical  murmur ;  at  others  it  is  loud,  harsh,  and  scraping ;  sometimes 
continuous,  sometimes  intermittent.  It  may  also  be  heard  at  any 
point  of  the  uterus,  but  most  frequently  low  down,  and  to  one  or  other 
side ;  more  rarely  above  the  umbilicus,  or  toward  the  fundus  ;  and  it 
often  changes  its  position  so  as  to  be  heard  at  a  subsequent  ausculta- 
tion at  a  point  where  it  was  previously  inaudible.  It  may  be  heard 
over  a  space  of  an  inch  or  two  only,  or  in  some  cases  over  the  whole 
uterine  tumor ;  or  again,  it  may  sometimes  be  detected  simultaneously 
over  two  entirely  distinct  portions  of  the  uterus.  It  is  generally  to 
be  heard  earlier  than  the  foetal  heart-sounds,  often  as  soon  as  the 
uterus  rises  above  the  brim  of  the  pelvis,  and  it  can  almost  always  be 
detected  after  the  commencement  of  the  fourth  month.  The  sound 
becomes  curiously  modified  by  the  uterine  contractions  during  labor, 
becoming  louder  and  more  intense  before  the  pain  comes  on,  disappear- 
ing during  its  acme,  and  again  being  heard  as  it  goes  off.  Hicks 
attributes  to  a  similar  cause,  viz.,  the  uterine  contractions  during 
pregnancy,  the  frequent  variations  in  the  sound  which  are  character- 
istic of  it.1  The  uterine  souffle  is  also  audible  after  the  death  of  the 
foetus,  and  it  is  believed  by  some  to  be  modified  and  to  become  more 
continuously  harsh  when  that  event  has  taken  place. 

Very  various  explanations  have  been  given  of  the  causes  of  this 
sound.  For  long  it  was  supposed  to  be  formed  in  the  vessels  of  the 
placenta,  and  hence  the  name  "placenta!  souffle,"  by  which  it  is  often 
talked  of;  or  if  not  in  the  placenta,  in  the  uterine  vessels  in  its  imme- 
diate neighborhood.  The  non-placental  origin  of  the  sound  is  suffi- 
ciently demonstrated  by  the  fact  that  it  may  be  heard  for  a  considerable 
time  after  the  expulsion  of  the  placenta.  Some  have  supposed  that  it 
is  not  formed  in  the  uterus  at  all,  but  in  the  maternal  vessels,  especially 
the  aorta  and  the  iliac  arteries,  owing  to  the  pressure  to  which  they 
are  subjected  by  the  gravid  uterus.  The  extreme  irregularity  of  the 
sound,  its  occasional  disappearance,  and  its  variable  site,  seem  to  be 
conclusive  against  this  view.  The  theory  which  refers  the  sound  to 
the  uterine  vessels  is  that  which  has  received  most  adherents,  and 
which  best  meets  the  facts  of  the  case ;  but  it  is  by  no  means  easy,  or 
even  possible,  to  account  for  the  exact  mode  of  its  production  in  them. 
Each  of  the  explanations  which  have  been  given  is  open  to  some 
objection.  It  is  far  from  unlikely  that  the  intermittent  contractions 
of  the  uterine  fibres,  which  are  known  to  occur  during  the  whole 
course  of  pregnancy,  may  have  much  to  do  with  it,  by  modifying,  at 
intervals,  the  rapidity  of  the  circulation  in  the  vessels.  Its  production 
in  this  manner  may  also  be  favored  by  the  chlorotic  state  of  the  blood, 
to  which  Cazeaux  and  Scanzoni  are  inclined  to  attribute  an  important 

i  Op.  cit.,p.  223. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  163 

influence,  likening  it  to  the  anamic  murmur  so  frequently  heard  in  the 
vessels  in  weakly  women. 

From  a  diagnostic  point  of  view  the  uterine  souffle  is  of  very 
secondary  importance,  because  a  similar  sound  is  very  generally 
audible  in  large  fibroid  tumors  of  the  uterus,  and  even  in  some  few 
ovarian  tumors ;  it  is,  therefore,  of  little  or  no  value  in  assisting  us  to 
decide  the  character  of  the  abdominal  enlargement.  The  supposed 
dependence  of  the  sound  on  the  placenta!  circulation  has  caused  its 
site  to  be  often  identified  with  that  of  the  placenta.  It  is,  however, 
most  frequently  heard  at  the  lower  part  of  the  uterus,  while  the 
placenta  is  generally  attached  near  the  fund  us,  so  that  its  position 
cannot  be  taken  as  any  safe  guide  in  determining  the  situation  of  that 
organ. 

Occasionally,  in  practising  auscultation,  irregular  sounds  of  brief 
duration  may  be  heard,  which  are  not  susceptible  of  accurate  descrip- 
tion, and  which  doubtless  depend  on  the  sudden  movement  of  the 
foetus  in  the  liquor  amnii,  or  on  the  impact  of  its  limbs  on  the  uterine 
walls.  When  heard  distinctly  they  are  characteristic  of  pregnancy ; 
and  they  may  be  sometimes  heard  when  the  other  sounds  cannot  be 
detected.  They  are,  however,  so  irregular,  and  so  often  entirely  absent, 
that  they  can  hardly  be  looked  upon  in  any  other  light  than  as  occa- 
sional phenomena. 

Two  other  sounds  have  been  described  as  being  sometimes  audible, 
which  may  be  mentioned  as  matters  of  interest,  but  which  are  of  no 
diagnostic  value.  One  is  a  rustling  sound,  said  by  Stoltz  to  be  audible 
in  cases  in  which  the  foetus  is  dead,  and  which  he  refers  to  gaseous 
decomposition  of  the  liquor  amnii ;  its  existence  is,  however,  extremely 
problematical.  The  other  is  a  sound  heard  after  the  birth  of  the  child, 
and  referred  by  Caillant  to  the  separation  of  the  placental  adhesions. 
He  describes  it  as  a  series  of  rapid  short  scratching  sounds,  similar  to 
those  produced  by  drawing  the  nails  across  the  seat  of  a  horsehair 
sofa.  Simpson1  admitted  the  existence  of  the  sound,  but  believed 
that  it  is  produced  by  the  mere  physical  crushing  of  the  placenta,  and 
artificially  imitated  it  out  of  the  body  by  forcing  the  placenta  through 
an  aperture  the  size  of  the  os  uteri. 

It  will  be  seen,  then,  that  although  there  are  numerous  signs  and 
symptoms  accompanying  pregnancy,  many  of  them  are  unreliable  by 
themselves,  and  apt*  to  mislead.  Those  which  may  be  confidently 
depended  on  are  the  pulsations  of  the  foetal  heart,  which,  however, 
fail  us  in  cases  of  dead  children ;  the  foetal  movements  when  distinctly 
made  out ;  ballottement ;  the  intermittent  contractions  of  the  uterus ; 
and  to  these  we  may  safely  add  the  presence  of  milk  in  the  breasts, 
provided  we  have  to  do  with  a  first  pregnancy. 

The  remainder  are  of  importance  in  leading  us  to  suspect  pregnancy, 
and  in  corroborating  and  strengthening  other  symptoms,  but  they  do 
not,  of  themselves,  justify  a  positive  diagnosis. 

\- 

i  Selected  Obstet.  Works,  p.  151. 


164  PREGNANCY. 


CHAPTER    Y. 

THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.— SPURIOUS 
PREGNANCY.— THE  DURATION  OF  PREGNANCY.— SIGNS  OF 
RECENT  PREGNANCY. 

THE  differential  diagnosis  of  pregnancy  has  of  late  years  assumed 
much  importance  on  account  of  the  advance  of  abdominal  surgery. 
The  cases  are  so  numerous  in  which  even  the  most  experienced  prac- 
titioners have  fallen  into  error,  and  in  which  the  abdomen  has  been 
laid  open  in  ignorance  of  the  fact  that  pregnancy  existed,  that  the 
subject  becomes  one  of  the  greatest  consequence.  Fortunately  it  is 
less  so  from  an  obstetrical  than  from  a  gynecological  point  of  view, 
inasmuch  as  the  converse  error,  of  mistaking  some  other  condition  for 
pregnancy,  is  of  far  less  consequence,  as  it  is  one  which  time  will 
always  rectify.  But  even  in  this  way  carelessness  may  lead  to  very 
serious  injury  to  the  character,  if  not  to  the  health,  of  the  patient ; 
and  it  will  be  well  to  refer  briefly  to  some  of  the  conditions  most  liable 
to  be  mistaken  for  pregnancy,  and  to  the  mode  of  distinguishing  them. 

Adipose  enlargement  of  the  abdomen  may  obscure  the  diagnosis  by 
preventing  the  detection  of  the  uterus ;  and  if,  as  is  not  uncommon 
with  women  of  great  obesity,  it  is  associated  with  irregular  menstrua- 
tion, the  increased  size  of  the  abdomen  might  be  supposed  to  depend 
on  pregnancy.  The  absence  of  corroborative  signs,  such  as  auscultatory 
phenomena,  mammary  changes,  and  the  hardness  of  the  cervix  as  felt 
•per  vaginam,  make  it  easy  to  avoid  this  error. 

Distention  of  the  uterus  by  retained  menstrual  fluid,  or  watery 
secretion,  is  an  occurrence  of  rarity  that  could  seldom  give  rise  to 
error.  Still,  it  occasionally  happens  that  the  uterus  becomes  enlarged 
in  this  way,  sometimes  reaching  even  to  the  level  of  the  umbilicus, 
and  that  the  physical  character  of  the  tumor  is  not  unlike  that  of  the 
gravid  uterus.  The  best  safeguard  against  mistakes  will  be  the  pre- 
vious history  of  the  case,  which  will  always  be  different  from  that  of 
ordinary  pregnancy.  Retention  of  the  menses  almost  always  occurs 
from  some  physical  obstruction  to  the  exit  of  the  fluid,  such  as  imper- 
forate  hymen  ;  or  if  it  occur  in  women  who  have  already  menstruated, 
we  may  usually  trace  a  history  of  some  cause,  such  as  inflammation 
following  an  antecedent  labor,  which  has  produced  occlusion  of  some 
part  of  the  genital  tract.  The  existence  of  a  pelvic  tumor  in  a  girl 
who  has  never  menstruated  will  of  itself  give  rise  to  suspicion,  as 
pregnancy  under  such  circumstances  is  of  extreme  rarit  v.  It  will  also 
be  found  that  general  symptoms  have  existed  for  a  period  of  time 
considerably  longer  than  the  supposed  duration  of  pregnancy  as 
judged  of  by  the  size  of  the  tumor.  The  most  characteristic  of  them 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  165 

are  periodic  attacks  of  pain  due  to  the  addition,  at  each  monthly- 
period,  to  the  quantity  of  retained  menstrual  fluid.  Whenever,  from 
any  of  these  reasons,  suspicion  of  the  true  character  of  the  case  has 
arisen,  a  careful  vaginal  examination  will  generally  clear  it  up.  In 
most  cases  the  obstruction  will  be  in  the  vagina,  and  is  at  once  de- 
tected, the  vaginal  canal  above  it,  as  felt  per  rectum,  being  greatly 
distended  by  fluid ;  and  we  may  also  find  the  bulging  and  imperforate 
hymen  protruding  through  the  vulva.  The  absence  of  mammary 
changes,  and  of  ballottement,  will  materially  aid  us  in  forming  a 
diagnosis. 

The  engorged  and  enlarged  uterus  frequently  met  with  in  women 
suffering  from  uterine  disease,  might  readily  be  mistaken  for  an  early 
pregnancy,  if  it  happened  to  be  associated  with  amenorrhcea.  A  little 
time  would,  of  course,  soon  clear  up  the  point,  by  showing  that  pro- 
gressive increase  in  size,  as  in  pregnancy,  does  not  take  place.  This 
mistake  could  only  be  made  at  an  early  stage  of  pregnancy,  when  a 
positive  diagnosis  is  never  possible.  The  accompanying  symptoms 
— pain,  inability  to  walk,  and  tenderness  of  the  uterus  on  pressure — 
would  prevent  such  an  error. 

Ascites,  per  se,  could  'hardly  be  mistaken  for  pregnancy ;  for  the 
uniform  distention  and  evident  fluctuation,  the  absence  of  any  definite 
tumor,  the  site  of  resonance  on  percussion  changing  in  accordance 
with  alteration  of  the  position  of  the  woman,  and  the  unchanged  cer- 
vix and  uterus,  should  be  sufficient  to  clear  up  any  doubt.  Pregnancy 
may,  however,  exist  with  ascites,  and  this  combination  may  be  difficult 
to  detect,  and  might  readily  be  mistaken  for  ovarian  disease  associated 
with  ascites.  The  existence  of  mammary  changes,  the  presence  of  the 
softened  cervix,  ballottement,  and  auscultation — provided  the  sounds 
were  not  masked  by  the  surrounding  fluid — would  aiford  the  best 
means  of  diagnosing  such  a  case. 

One  of  the  most  frequent  sources  of  difficulty  is  the  differential 
diagnosis  of  large  abdominal  tumors,  either  fibroid  or  ovarian,  or  of 
some  enlargements  due  to  malignant  disease  of  the  peritoneum  or 
abdominal  viscera.  The  most  experienced  have  been  occasionally 
deceived  under  such  circumstances.  As  a  rule,  the  presence  of  men- 
struation will  prevent  error,  as  this  generally  continues  in  ovarian 
disease,  while  in  fibroids  it  is  often  excessive.  The  character  of  the 
tumor — the  fluctuation  in  ovarian  disease,  the  hard  nodular  masses  in 
fibroid — and  the  history  of  the  case — especially  the  length  of  time 
the  tumor  has  existed — will  aid  in  diagnosis,  while  the  absence  of 
cervical  softening  (vide  p.  1 43)  and  of  auscultatory  phenomena  will 
further  be  of  material  value  in  forming  a  conclusion.  Some  of  the 
most  difficult  cases  to  diagnose  are  those  in  which  pregnancy  compli- 
cates ovarian  or  fibroid  disease.  Then  the  tumor  may  more  or  less 
completely  obscure  the  physical  signs  of  pregnancy.  The  usual  shape 
of  the  abdomen  will  generally  be  altered  considerably,  and  we  may 
be  able  to  distinguish  the  gravid  uterus,  separated  from  the  ovarian 
tumor  by  a  distinct  sulcus,  or  with  the  fibroid  masses  cropping  out 
from  its  surface.  Our  chief  reliance  must  then  be  placed  in  the  altera- 
tion of  the  cervix,  and  in  the  auscultatory  signs  of  pregnancy. 


166  PREGNANCY. 

Spurious  Prog-nancy . — The  condition  most  likely  to  give  rise  to 
errors  is  that  very  interesting  and  peculiar  state  known  as  spurious 
pregnancy,  or  pseudocyesis.  In  this,  most  of  the  usual  phenomena  of 
pregnancy  are  so  strangely  simulated  that  accurate  diagnosis  is  often 
far  from  easy.  There  are  hardly  any  of  the  more  apparent  symptoms 
of  pregnancy  which  may  not  be  present  in  marked  cases  of  this  kind. 
The  abdomen  may  become  prominent,  the  areolse  altered,  menstrua- 
tion arrested,  and  apparent  foetal  motions  felt ;  and,  unless  suspicion  is 
aroused,  and  a  careful  physical  examination  made,  both  the  patient 
and  the  practitioner  may  easily  be  deceived. 

There  is  no  period  of  the  childbearing  life  in  which  spurious  preg- 
nancy may  not  be  met  with,  but  it  is  most  likely  to  occur  in  elderly 
women  about  the  climacteric  period,  when  it  is  generally  associated 
with  ovarian  irritation  connected  with  the  change  of  life ;  or  in 
younger  women,  who  are  either  very  desirous  of  finding  themselves 
pregnant,  or  who,  being  unmarried,  have  subjected  themselves  to  the 
chance  of  being  so.  In  all  cases  the  mental  faculties  have  much  to 
do  with  its  production,  and  there  is  generally  either  very  marked 
hysteria,  or  even  a  condition  closely  allied  to  insanity.  Spurious 
pregnancy  is  by  no  means  confined  to  the  'human  race.  It  is  well 
known  to  occur  in  many  of  the  lower  animals.  Harvey  related  in- 
stances in  bitches,  either  after  unsuccessful  intercourse,  or  in  connec- 
tion with  their  being  in  heat,  even  when  no  intercourse  had  occurred. 
In  such  cases  the  abdomen  swelled,  and  milk  appeared  in  the  mammas. 
Similar  phenomena  are  also  occasionally  met  with  in  the  cow.  In 
these  instances,  as  in  the  human  female,  there  is  probably  some 
morbid  irritation  of  the  ovarian  system. 

The  physical  phenomena  are  often  very  well  marked.  The  apparent 
enlargement  is  sometimes  very  great,  and  it  seems  to  be  produced  by 
a  projection  forward  of  the  abdominal  contents  due  to  depression  of 
the  diaphragm,  together  with  rigidity  of  the  abdominal  muscles,  and 
may  even  closely  simulate  the  uterine  tumor  on  palpation.  After  the 
climacteric  it  is  frequently  associated,  as  Gooch  pointed  out,  with  an 
undue  deposit  of  fat  in  the  abdominal  walls  and  omentum,  so  that 
there  may  be  even  some  dulness  on  percussion,  instead  of  resonance  of 
the  intestines.  The  foetal  movements  are  curiously  and  exactly  simu- 
lated, either  by  involuntary  contractions  of  the  abdominal  walls,  or 
by  the  movement  of  flatus  in  the  intestines.  The  patient  also  gener- 
ally fancies  that  she  suffers  from  the  usual  sympathetic  disorders  of 
pregnancy,  and  thus  her  account  of  her  symptoms  will  still  further 
tend  to  mislead. 

Not  only  may  the  supposed  pregnancy  continue,  but,  at  what  would 
be  the  natural  term  of  delivery,  all  the  phenomena  of  labor  may 
supervene.  Many  authentic  cases  are  on  record  in  which  regular 
pains  came  on,  and  continued  to  increase  in  force  and  frequency  until 
the  actual  condition  was  diagnosed.  Such  mistakes,  howrever,  are  only 
likely  to  happen  w^hen  the  statements  of  the  patient  have  been  received 
without  further  inquiry.  When  once  an  accurate  examination  has 
been  made,  error  is  no  longer  possible. 

We  shall  generally  find  that  some  of  the  phenomena  of  pregnancy 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  167 

are  absent.  Possibly  menstruation,  more  or  less  irregular,  may  have 
continued.  Examination  per  vayinam  will  at  once  clear  up  the  case, 
by  showing  that  the  uterus  is  not  enlarged,  and  that  the  cervix  is 
unaltered.  It  may  then  be  very  difficult  to  convince  the  patient  or 
her  friends  that  her  symptoms  have  misled  her,  and  for  this  purpose 
the  inhalation  of  chloroform  is  of  great  value.  As  consciousness  is 
abolished,  the  semi- voluntary  projection  of  the  abdominal  muscles  is 
prevented,  the  large  apparent  tumor  vanishes,  and  the  bystanders  can 
be  readily  convinced  that  none  exists.  As  the  patient  recovers  the 
tumor  again  appears. 

Duration  of  Pregnancy. — The  duration  of  pregnancy  in  the  human 
female  has  always  formed  a  fruitful  theme  for  discussion  among  ob- 
stetricians. The  reasons  which  render  the  point  difficult  of  decision 
are  obvious.  As  the  large  majority  of  cases  occur  in  married  women, 
in  whom  intercourse  occurs  frequently,  there  is  no  means  of  knowing 
the  precise  period  at  which  conception  took  place.  The  only  datum 
which  exists  for  the  calculation  of  the  probable  date  of  delivery  is  the 
cessation  of  menstruation.  It  is  quite  possible,  however,  and  indeed 
probable,  that  conception  occurred,  in  a  considerable  number  of  in- 
stances, not  immediately  after  the  last  period,  but  immediately  before 
the  proper  epoch  for  the  occurrence  of  the  next.  Hence,  as  the  inter- 
val between  the  end  of  one  menstruation  and  the  commencement  of 
the  next  averages  twenty-five  days,  an  error  to  that  extent  is  always 
possible.  Another  source  of  fallacy  is  the  fact,  which  has  generally 
been  overlooked,  that  even  a  single  coitus  does  not  fix  the  date  of 
conception,  but  only  that  of  insemination.  It  is  well  known  that  in 
many  of  the  lower  animals  the  fertilization  of  the  ovule  does  not  take 
place  until  several  days  after  copulation,  the  spermatozoa  remaining  in 
the  interval  in  a  state  of  active  vitality  within  the  genital  tract.  It 
has  been  shown  by  Marion  Sims  that  living  spermatozoa  exist  in  the 
cervical  canal  in  the  human  female  some  days  after  intercourse.  It  is 
very  probable,  therefore,  that  in  the  human  female,  as  in  the  lower 
animals,  a  considerable  but  unknown  interval  occurs  between  insem- 
ination and  actual  impregnation,  which  may  render  calculations  as  to 
the  precise  duration  of  pregnancy  altogether  unreliable. 

A  large  mass  of  statistical  observations  exist  respecting  the  average 
duration  of  gestation,  which  have  been  drawn  up  and  collated  from 
numerous  sources.  It  would  serve  no  practical  purpose  to  reprint  the 
voluminous  tables  on  this  subject  that  are  contained  in  obstetrical 
works.  They  are  based  on  two  principal  methods  of  calculation. 
First,  we  have  the  length  of  time  between  the  cessation  of  menstruation 
and  delivery.  This  is  found  to  vary  very  considerably,  but  the  largest 
percentage  of  deliveries  occurs  between  the  274th  and  280th  day  after 
the  cessation  of  menstruation,  the  average  day  being  the  278th  ;  but, 
in  individual  instances,  very  considerable  variations  both  above  and 
below  these  limits  are  found  to  exist.  Next  we  have  a  series  of  cases, 
from  various  sources,  in  which  only  one  coitus  was  believed  to  have 
taken  place.  These  are  naturally  always  open  to  some  doubt,  but,  on 
the  whole,  they  may  be  taken  as  affording  tolerably  fair  grounds  for 
calculation.  Here,*  as  in  the  other  mocle  of  calculation,  there  are 


168  PREGNANCY. 

marked  variations,  the  average  length  of  time,  as  estimated  from  a 
considerable  collection  of  cases,  being  275  days  after  the  single  inter- 
course. It  may,  therefore,  be  taken  as  certain  that  there  is  no  definite 
time  which  we  can  calculate  on  as  being  the  proper  duration  of  preg- 
nancy, and,  consequently,  no  method  of  estimating  the  probable  date 
of  delivery  on  which  we  can  absolutely  rely. 

Methods  of  Predicting  the  Probable  Date  of  Delivery. — The 
prediction  of  the  time  at  which  the  confinement  may  be  expected  is, 
however,  a  point  of  considerable  practical  importance,  and  one  on 
which  the  medical  attendant  is  always  consulted.  Various  methods 
of  making  the  calculation  have  been  recommended.  It  has  been 
customary  in  this  country,  according  to  th,e  recommendation  of  Mont- 
gomery, to  fix  upon  ten  lunar  months,  or  280  days,  as  the  probable 
period  of  gestation,  and,  as  conception  is  supposed  to  occur  shortly 
after  the  cessation  of  menstruation,  to  add  this  number  of  days  to  any 
day  within  the  first  week  after  the  last  menstrual  period  as  the  most 
probable  period  of  delivery.  As,  however,  278  days  is  found  to  be 
the  average  duration  of  gestation  after  the  cessation  of  menstruation, 
and  as  the  method  makes  the  calculation  vary  from  281  to  287  days,  it 
is  evidently  liable  to  fix  too  late  a  date.  Naegele's  method  was  to  count 
seven  days  from  the  first  appearance  of  the  last  menstrual  period,  and 
then  reckon  backward  three  months  as  the  probable  date.  Thus,  if  a 
patient  last  commenced  to  menstruate  on  August  10,  counting  in  this 
way  from  August  17  would  give  May  17  as  the  probable  date  of  the 
delivery. 

Matthews  Duncan  has  paid  more  attention  than  anyone  else  to  the 
prediction  of  the  date  of  delivery.  His  method  of  calculating  is  based 
on  the  fact  of  278  days  being  the  average  time  between  the  cessation 
of  menstruation  and  parturition ;  and  he  claims  to  have  had  a  greater 
average  of  success  in  his  predictions  than  on  any  other  plan.  His 
rule  is  as  follows:  "Find  the  day  on  which  the  female  ceased  to- 
menstruate,  or  the  first  day  of  being  what  she  calls  '  well.'  Take  that 
day  nine  months  forward  as  275 — unless  February  is  included,  in 
which  case  it  is  taken  as  273 — days.  To  this  add  three  days  in  the 
former  case,  or  five  if  February  is  in  the  count,  to  make  up  the  278. 
This  278th  day  should  then  be  fixed  on  as  the  middle  of  the  week,  or, 
to  make  the  prediction  more  accurate,  of  the  fortnight  in  which  the 
confinement  is  likely  to  occur,  by  which  means  allowance  is  made  for 
the  average  variation  of  either  excess  or  deficiency." 

Various  periodoscopes  and  tables  for  facilitating  the  calculation 
have  been  made.  The  periodoscope  of  Dr.  Tyler  Smith  is  very  useful 
for  reference  in  the  consulting-room,  giving  at  a  glance  a  variety  of 
information,  such  as  the  probable  period  of  quickening,  the  dates  for  the 
induction  of  premature  labor,  etc.  The  following  table,  prepared  by  Dr. 
Protheroe  Smith,  is  also  easily  read,  and  is  very  serviceable  : 


169 


TABLE  FOR  CALCULATING  THE  PERIOD  OF  UTERO-GESTATION.  1 


Nine  calendar  months. 

Ten  lunar  months. 

From 

To 

Days. 

To 

Days. 

January        1 

September 

30 

273 

October 

7 

280 

February      1 

October 

31 

273 

November 

7 

280 

March            1 

November 

30 

275 

December 

5 

280 

April              1 

December 

31 

275 

January 

5 

280 

May               1 

January 

31 

27G 

February 

4 

280 

June              1 

February 

28 

273 

March 

7 

280 

July               1 

March 

31 

274 

April 

6 

280 

August          1 

April 

30 

273 

May 

7 

280 

September    1 

May 

31 

273 

June 

7 

280 

October         1 

June 

30 

273 

July 

7 

280 

November     1 

July 

31 

273 

August 

7 

280 

December      1 

August 

31 

274 

September 

6 

280 

The  date  at  which  the  quickening  has  been  perceived  is  relied  on 
by  many  practitioners,  and  still  more  by  patients,  in  calculating  the 
probable  date  of  delivery,  as  it  is  generally  supposed  to  occur  at  the 
middle  of  pregnancy.  The  great  variations,  however,  of  the  time  at 
which  this  phenomenon  is  first  perceived,  and  the  difficulty  which  is 
so  often  experienced  of  ascertaining  its  presence  with  any  certainty, 
render  it  a  very  fallacious  guide.  The  only  times  at  which  the  per- 
ception of  quickening  is  likely  to  prove  of  any  real  value  are  when 
impregnation  has  occurred  during  lactation  (when  menstruation  is 
normally  absent),  or  when  menstruation  is  so  uncertain  and  irregular 
that  the  date  of  its  last  appearance  cannot  be  ascertained.  As  quick- 
ening is  most  commonly  felt  during  the  fourth  month,  more  frequently 
in  its  first  than  in  its  last  fortnight,  it  may  thus  afford  the  only  guide 
we  can  obtain,  and  that  an  uncertain  one,  for  predicting  the  date  of 
delivery. 

Is  Protraction  of  Gestation  Possible? — From  a  medico-legal 
point  of  view  the  question  of  the  possible  protraction  of  pregnancy 
beyond  the  average  time,  and  of  the  limits  within  which  such  pro- 
traction can  be  admitted,  is  of  very  great  importance.  The  law  on 
this  point  varies  considerably  in  different  countries.  Thus,  in  France 
it  is  laid  down  that  legitimacy  cannot  be  contested  until  300  days 
have  elapsed  from  the  death  of  the  husband,  or  the  latest  possible 
opportunity  for  sexual  intercourse.  This  limit  is  also  adopted  by 
Austria,  while  in  Prussia  it  is  fixed  at  302  days.  In  England  and 
America  no  fixed  date  is  admitted,  but  while  280  days  is  admitted  as 
the  "  legitimum  tempus  pariendi,"  each  case  in  which  legitimacy  is 
questioned  is  to  be  decided  on  its  own  merits.  At  the  early  part  of 
the  century  the  question  was  much  discussed  by  the  leading  obstetricians 
in  connection  with  the  celebrated  Gardner  peerage  case,  and  a  con- 
siderable difference  of  opinion  existed  among  them.  Since  that  time 
many  apparently  perfectly  reliable  cases  have  been  recorded,  in  which 

1  The  above  obstetric  "Ready  Reckoner"  consists  of  two  columns,  one  of  calendar,  the  other  of 
lunar,  mouths,  and  may  be  read  as  follows :  A  patient  has  ceased  to  menstruate  ou  July  1 :  her 
confinement  may  be  expected  at  soonest  about  March  31  (the  end  of  nine  calendar  months) ;  or  at 
latest  on  April  6  (the  end  of  ten  lunar  months).  Another  has  ceased  to  menstruate  on  January  20  ; 
her  confinement  may  be  expected  on  September  30,  plus  twenty  days  (the  end  of  nine  calendar 
months),  at  soonest ;  or  on  October  7,  plus  twenty  days  (the  end  of  ten  lunar  months),  at  latest. 


170  PREGNANCY. 

the  duration  of  gestation  -was  obviously  much  beyond  the  average,  and 
in  which  all  sources  of  fallacy  were  carefully  excluded. 

Xot  to  burden  these  pages  with  a  number  of  cases,  it  may  suffice  to 
refer,  as  examples  of  protraction,  to  four  well-known  instances  recorded 
by  Simpson/  in  which  the  pregnancy  extended  respectively  to  336, 
332,  319,  and  324  days  after  the  cessation  of  the  last  menstrual  period. 
In  these,  as  in  all  cases  of  protracted  gestation,  there  is  the  possible 
source  of  error  that  impregnation  may  have  occurred  just  before  the 
expected  advent  of  the  next  period.  Making  an  allowance  of  23  days 
in  eacli  instance  for  this,  we  even  then  have  a  number  of  days  much 
above  the  average,  viz.,  313,  309,  296,  and  301.  Numerous  instances 
as  curious  may  be  found  scattered  through  obstetric  literature.  Indeed, 
the  experience  of  most  acccoucheurs  will  parallel  such  cases,  which 
may  be  more  common  than  is  generally  supposed,  inasmuch  as  they 
are  only  likely  to  attract  attention  when  the  husband  has  been  sepa- 
rated from  the  wife  beyond  the  average  and  expected  duration  of  the 
pregnancy. 

The  evidence  in  favor  of  the  possible  prolongation  of  gestation  is 

freatly  strengthened  by  what  is  known  to  occur  in  the  lower  animals. 
n  some  of  these,  as  in  the  cow  and  the  mare,  the  precise  period  of 
insemination  is  known  to  a  certainty,  as  only  a  single  coitus  is  per- 
mitted. Many  tables  of  this  kind  have  been  constructed,  and  it  has 
been  shown  that  there  is  in  them  a  very  considerable  variation.  In 
some  cases  in  the  cow  it  has  been  found  that  delivery  took  place  45 
days,  and  in  the  mare  43  days,  after  the  calculated  date.  Analogy 
would  go  strongly  to  show  that  what  is  known  to  a  certainty  to  occur 
in  the  lower  animals  may  also  take  place  in  the  human  female.  The 
fact,  indeed,  is  now  very  generally  admitted;  but  we  are  still  unable 
to  fix,  with  any  degree  of  precision,  on  the  extreme  limit  to  which 
protraction  is  possible.  Some  practitioners  have  given  cases  in  which, 
on  data  which  they  believe  to  be  satisfactory,  pregnancy  has  been 
extremely  protracted ;  thus  Meigs  and  Adler  record  instances  which 
they  believed  to  have  been  prolonged  to  over  a  year  in  one  case,  and 
over  fourteen  months  in  the  other.  These  are,  however,  so  problem- 
atical that  little  weight  can  be  attached  to  them.  On  the  whole,  it 
would  hardly  be  safe  to  conclude  that  pregnancy  can  go  more  than 
three  or  four  weeks  beyond  the  average  time.  This  conclusion  is  jus- 
tified by  the  cases  we  possess  in  which  pregnancy  followed  a  single 
coitus,  the  longest  of  which  was  295  days. 

Dr.  Duncan  *  is  inclined  to  refuse  credence  to  every  case  of  supposed 
protraction  unless  the  size  and  weight  of  the  child  are  above  the 
average,  believing  that  lengthened  gestation  must  of  necessity  cause 
increased  growth  of  the  child.  This  point  requires  further  investiga- 
tion, and  it  cannot  be  taken  as  proved  that  the  foetus  necessarily  must 
be  large  because  it  has  been  retained  longer  than  usual  in  utero  ;  or, 
even  if  this  be  admitted,  it  may  have  been  originally  small,  and  so,  at 
the  end  of  the  protracted  gestation,  be  little  above  the  average  weight. 
There  are,  however,  many  cases  which  certainly  prove  that  a  prolonged 

1  Obstet.  Memoirs,  p.  84. 

2  Fecundity  arid  Fertility,  p.  348. 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  171 

pregnancy  is  at  least  often  associated  with  an  unusually  developed 
foetus.  Dr.  Duncan  himself  cites  several,  and  a  very  interesting  one 
is  mentioned  by  Leishman,  in  which  delivery  took  place  295  days  after 
a  single  coitus,  the  child  weighing  12  Ibs.  3  oz. 

It  seems  possible  that,  in  some  cases  of  protracted  pregnancy,  labor 
actually  came  on  at  the  average  time,  but,  on  account  of  faulty  posi- 
tions of  the  uterus  or  other  obstructing  cause,  the  pains  were  ineffective 
and  ultimately  died  away,  not  recurring  for  a  considerable  time. 
Joulin  relates  some  instances  of  this  kind.  In  one  of  them  the  labor 
was  expected  from  the  20th  to  the  25th  of  October.  He  was  sum- 
moned on  the  23d,  and  found  the  pains  regular  and  active,  but  inef- 
fective ;  after  lasting  the  whole  of  the  24th  and  25th  they  died  away, 
and  delivery  did  not  take  place  until  November  25th,  after  the  lapse 
of  a  month.  In  this  instance  the  apparent  cause  of  difficulty  was 
extreme  anterior  obliquity  of  the  uterus.  A  precisely  similar  case 
came  under  my  own  observation.  The  lady  ceased  to  menstruate  on 
March  16,  1870.  On  December  12th,  that  is,  on  the  273d  day,  strong 
labor  pains  came  on,  the  os  dilated  to  the  size  of  a  florin,  and  the 
membranes  became  tense  and  prominent  with  each  pain.  After  last- 
ing all  night  they  gradually  died  away,  and  did  not  recur  until 
January  12th,  304  days  from  the  cessation  of  the  last  period.  Here 
there  was  no  assignable  cause  of  obstruction,  and  the  labor,  when  it 
did  come  on,  was  natural  and  easy. 

The  curious  fact  that  in  both  these  cases,  as  in  others  of  the  same 
kind  that  are  recorded,  labor  came  on  exactly  a  month  after  the 
previous  ineffectual  attempt  at  its  establishment,  affords,  so  far  as  it 
goes,  an  argument  in  favor  of  the  view  maintained  by  many  that  labor 
is  apt  to  come  on  at  what  would  have  been  a  menstrual  period. 

Signs  of  Recent  Delivery. — From  a  forensic  point  of  view  it 
often  becomes  of  importance  to  be  able  to  give  a  reliable  opinion  as 
to  the  fact  of  delivery  having  occurred,  and  a  few  words  may  be  here 
said  as  to  the  signs  of  recent  delivery.  Our  opinion  is  only  likely  to 
be  sought  in  cases  in  which  the  fact  of  delivery  is  denied,  and  in  which 
we  must,  therefore,  entirely  rely  on  the  results  of  a  physical  examina- 
tion. If  this  be  undertaken  within  the  first  fortnight  after  labor,  a 
positive  conclusion  can  be  readily  arrived  at. 

At  this  time  the  abdominal  walls  will  still  be  found  loose  and  flaccid, 
and  bearing  very  evident  marks  of  extreme  disteutiou  in  the  cracks 
and  fissures  of  the  cutis  vera.  These  remain  permanent  for  the  rest 
of  the  patient's  life,  and  may  be  safely  assumed  to  be  signs  of  an 
antecedent  pregnancy,  provided  we  can  be  certain  that  no  other  cause 
of  extreme  abdominal  distention  has  existed,  such  as  ascites  or  ovarian 
tumor. 

Within  the  first  few  days  after  delivery,  the  hard  round  ball  formed 
by  the  contracted  and  empty  uterus  can  easily  be  felt  by  abdominal 
palpation,  and  more  certainly  by  combined  external  and  internal  ex- 
amination. The  process  of  involution,  however,  by  which  the  uterus 
is  reduced  to  its  normal  size,  is  so  rapid  that  after  the  first  week  it 
can  no  longer  be  made  out  above  the  brim  of  the  pelvis.  In  cases  in 
Avhich  an  accurate  diagnosis  is  of  importance,  the  increased  length  of 


172  PREGNANCY. 

the  uterus  can  be  ascertained  by  the  uterine  sound,  and  its  cavity  will 
measure  more  than  the  normal  two  and  a  half  inches  for  at  least  a 
month  after  delivery.  It  should  not  be  forgotten  that  the  uterine 
parietes  are  now  undergoing  fatty  degeneration,  and  that  they  are 
more  than  usually  soft  and  friable,  so  that  the  sound  should  be  used 
with  great  caution,  and  only  when  a  positive  opinion  is  essential.  The 
state  of  the  cervix  and  of  the  vagina  may  afford  useful  information. 
Immediately  after  delivery  the  cervix  hangs  loose  and  patulous  in  the 
vagina,  but  it  rapidly  contracts,  and  the  internal  os  is  generally 
entirely  closed  after  the  eighth  or  tenth  day.  The  remainder  of  the 
cervix  is  longer  in  returning  to  its  normal  shape  and  consistency.  It 
is  generally  permanently  altered  after  delivery,  the  external  os  remain- 
ing fissured  and  transverse,  instead  of  circular  with  smooth  margins, 
as  in  virgins.  The  vagina  is  at  first  lax,  swollen,  and  dilated,  but 
these  signs  rapidly  disappear,  and  cannot  be  satisfactorily  made  out 
after  the  first  few  days.  The  absence  of  the  fourchette  may  be  recog- 
nized, and  is  a  persistent  sign. 

The  presence  of  the  lochia  affords  a  valuable  sign  of  recent  delivery. 
For  the  first  few  days  they  are  sanguineous,  and  contain  numerous 
blood  corpuscles,  epithelial  scales,  and  the  debris  of  the  decidua. 
After  the  fifth  day  they  generally  change  in  color,  and  become  pale 
and  greenish,  and  from  the  eighth  or  ninth  day  till  about  a  month 
after  delivery  they  have  the  appearance  of  thick  opalescent  mucus. 
They  have,  however,  a  peculiar,  heavy,  sickening  odor,  which  should 
prevent  their  being  mistaken  for  either  menstruation  or  leucorrhoeal 
discharge. 

The  appearance  of  the  breasts  will  also  aid  the  decision,  for  it  is 
impossible  for  the  patient  to  conceal  the  turgid,  swollen  condition  of 
the  mammae,  with  the  darkened  areolse,  and,  above  all,  the  presence 
of  milk.  If,  on  microscopic  examination,  the  milk  is  found  to  contain 
colostrum  corpuscles,  the  fact  of  very  recent  delivery  is  certain.  In 
women  who  do  not  nurse  it  should  be  remembered  that  the  secretion 
of  milk  often  rapidly  disappears,  so  that  its  absence  cannot  be  taken 
as  a  sign  that  delivery  has  not  taken  place.  On  the  whole,  there 
should  be  no  difficulty  in  deciding  that  a  woman  has  been  delivered, 
as  some  of  the  signs  are  persistent  for  the  rest  of  her  life ;  but  it  is  not 
so  easy,  unless  we  see  the  case  within  the  first  eight  or  ten  days,  to 
say  how  long  it  is  since  labor  took  place. 


ABNORMAL    PREGNANCY. 


173 


CHAPTER   VI. 

ABNORMAL  PREGNANCY,  INCLUDING  MULTIPLE  PREGNANCY, 
SUPERFCETATION,  EXTRA-UTERINE  FCETATION,  AND  MISSED 
LABOR. 

THE  occurrence  of  more  than  one  foetus  in  utero  is  far  from  un- 
common, but  there  are  circumstances  connected  with  it  which  justify 
the  conclusion  that  plural  births  must  not  be  classified  as  natural  forms 
of  pregnancy.  The  reasons  for  this  statement  have  been  well  collected 
by  Dr.  Arthur  Mitchell,1  who  conclusively  shows  that  not  only  is 
there  a  direct  increase  of  risk  to  the  mother  and  her  offspring,  but 
that  many  abnormalities,  such  as  idiocy,  imbecility,  and  bodily  de- 
formity, occur  with  much  greater  frequency  in  twins  than  in  single- 
born  children.  He  concludes  that  "  the  whole  history  of  twin  births 
is  exceptional,  indicates  imperfect  development  and  feeble  organization 
in  the  product,  and  leads  us  to  regard  twinning  in  the  human  species 
as  a  departure  from  the  physiological  rule,  and  therefore  injurious  to 
all  concerned." 

The  frequency  of  multiple  births  varies  considerably  under  dif- 
ferent circumstances.  Taking  the  average  of  a  large  number  of  cases 
collected  by  authors  in  various  countries,  we  find  that  twin  pregnancies 
occur  about  once  in  87  labors ;  triplets  once  in  7679.  A  certain  num- 
ber of  quadruple  pregnancies,  and  some  cases  of  early  abortion  in 
which  there  were  five  foetuses,  are  recorded,  so  that  there  can  be  no 
doubt  of  the  possibility  of  such  occurrences ;  but  they  are  so  extremely 
uncommon  that  they  may  be  looked  upon  as  rare  exceptions,  the 
relative  frequency  of  which  can  hardly  be  determined. 

The  frequency  of  multiple  pregnancy  varies  remarkably  in  different 
races  and  countries.  The  following  table2  will  show  this  at  a  glance  : 

RELATIVE  FREQUENCY  OF  MULTIPLE  PREGNANCIES  IN  EUROPE. 


Countries. 

Proportion  of 
twin  to  single 
births. 

Proportion  of 
triplets. 

Proportion  of 
quadruplets. 

1 

\ 
\ 
1 

1 

116 
94 
89 
95 
99 
64 
68.9 
81.62 
89 
50.05 
79 
102 
862 

1 
1 
1 

1 
1 

1 

6,720 
6,575 

8,256 
4,995 
6,436 
5,442 
7,820 
4,054 
1,000 

6,464 

1 
1 

1 

1 
1 

2,074,306 
167,226 
183,236 

394,690 
400,000 
110,991 

Grand  Duchy  of  Baden      .... 
Scotland     ....... 

Meckleiibnrg-Schwerin      .... 

Med.  Times  and  Gaz..  Nov.  1862. 
Puech  :  Des  Naissances  Multiples. 


174  PREGNANCY. 

It  will  be  seen  that  the  largest  proportion  of  multiple  births  occurs  in 
Russia,  and  that  the  number  of  triple  births  is  greatest  where  twin 
pregnancies  are  most  frequent.  Puech  concludes  that  the  number  of 
multiple  pregnancies  is  in  direct  proportion  to  the  general  fecundity 
of  the  inhabitants. 

Dr.  Duncan  has  deduced  some  interesting  laws,  with  regard  to  the 
production  of  twins,  from  a  large  number  of  statistical  observations ;' 
especially  that  the  tendency  to  the  production  of  twins  increases  as  the 
age  of  the  woman  advances,  and  is  greater  in  each  succeeding  pregnancy, 
exception  being  made  for  the  first  pregnancy,  in  which  it  is  greater  than 
in  any  other.  Newly  married  women  appear  more  likely  to  have  twins 
the  older  they  are.  There  can  be  no  doubt  that  there  is  often  a  strong 
hereditary  tendency  in  individual  families  to  multiple  births.  A 
remarkable  instance  of  this  kind  is  recorded  by  Mr.  Curgenven,2  in 
which  a  woman  had  four  twin  pregnancies,  her  mother  and  aunt  each 
one,  and  her  grandmother  two.  Simpson  mentions  a  case  of  quadruplets, 
consisting  of  three  males  and  one  female,  who  all  survived,  the  female 
subsequently  giving  birth  to  triplets.3 

Sex  of  Children. — In  the  largest  number  of  cases  of  twins  the 
children  are  of  opposite'  sexes,  next  most  frequently  there  are  two 
females,  and  twin  males  are  the  most  uncommon.  Thus,  out  of 
59,178  labors,  Simpson  calculates  that  twin  male  and  female  occurred 
once  in  199  labors,  twin  females  once  in  226,  and  twin  males  once  in 
258.  The  proportion  of  male  to  female  births  is  also  notably  less  in 
twin  than  in  single  pregnancies. 

Size  of  Foetuses. — Twins,  and  a  fortiori  triplets,  are  almost  always 
smaller  and  less  perfectly  developed  than  single  children.  Hence  the 
chances  of  their  survival  are  much  less,  and  Clarke  calculates  the 
mortality  amongst  twin  children  as  one  out  of  thirteen.  Of  triplets, 
indeed,  it  is  comparatively  rare  that  all  survive ;  while  in  quadruplets, 
premature  labor  and  the  death  of  foetuses  are  almost  certain.  It  is  a 
common  observation  that  twins  are  often  unequally  developed  at  birth. 
By  some  this  difference  is  attributed  to  one  of  them  being  of  a  different 
age  to  the  other.  It  is  probable,  however,  that  in  most  of  these  cases, 
the  full  development  of  one  foetus  has  been  interfered  with  by  pressure 
of  the  other.  This  is  far  from  uncommonly  carried  to  the  extent  of 
destroying  one  of  the  twins,  which  is  expelled  at  term,  mummified 
and  flattened  between  the  living  child  and  the  uterine  wall.  In  other 
cases,  when  one  foetus  dies  it  may  be  expelled  without  terminating  the 
pregnancy,  the  other  being  retained  in  utero  and  born  at  term ;  and 
those  who  disbelieve  in  the  possibility  of  superfoetation  explain  in  this 
way  the  cases  in  which  it  is  believed  to  have  occurred. 

Multiple  pregnancies  depend  on  various  causes.  The  most  common 
is  probably  the  simultaneous,  or  nearly  simultaneous,  maturation  and 
rupture  of  two  Graafian  follicles,  the  ovules  becoming  impregnated  at 
or  about  the  same  time.  It  by  no  means  necessarily  follows,  even  if 
more  than  one  follicle  should  rupture  at  once,  that  both  ovules  should 

i  On  Fecundity,  Fertility,  and  Sterility,  p.  99. 
*  Obst.  Trans., "1870.  vol.'xi.  p.  106. 
8  Obst.  Works,  p.  830. 


ABNORMAL    PREGNANCY.  175 

be  impregnated.  This  is  proved  by  the  occurrence  of  cases  in  which 
there  are  two  corpora  lutea  with  only  one  foetus.  There  are  numerous 
facts  to  prove  that  ovules  thrown  off  within  a  short  time  of  each  other 
may  become  separately  impregnated,  as  in  cases  in  which  negro  women 
have  given  birth  to  twins,  one  of  which  was  pure  negro,  the  other 
half-caste. 

It  may  happen,  however,  that  a  single  Graafian  follicle  contains 
more  than  one  ovule,  as  has  actually  been  observed  before  its  rupture ; 
or,  as  is  not  uncommon  in  the  egg  of  the  fowl,  an  ovule  may  contain  a 
double  germ,  each  of  which  may  give  rise  to  a  separate  foetus. 

Arrangement  of  the  Foetal  Membranes  and  Placentae. — The 
various  modes  in  which  twins  may  originate  explain  satisfactorily  the 
variations  which  are  met  with  in  the  arrangement  of  the  foetal  mem- 
branes, and  in  the  form  and  connections  of  the  placenta?.  In  a  large 
proportion  of  cases  there  are  two  distinct  bags  of  membranes,  the 
septum  between  them  being  composed  of  four  layers,  viz.,  the  chorion 
and  amnion  of  each  ovum.  The  placentae  are  also  entirely  separate. 
Here  it  is  obvious  that  each  twin  is  developed  from  a  distinct  ovum, 
having  its  own  chorion  and  amnion.  On  arriving  in  the  uterus  it  is 
probable  that  each  ovum  becomes  fixed  independently  in  the  mucous 
membrane,  and  is  surrounded  by  its  own  decidua  reflexa.  As  growth 
advances  the  decidua  reflexa  generally  atrophies  from  pressure,  as  it  is 
not  usual  to  find  more  than  four  layers  of  membrane  in  the  septum 
separating  the  ova.  In  other  cases  there  is  only  one  chorion,  within 
which  are  two  distinct  amnions,  the  septum  then  consisting  of  two 
layers  only.  Then  the  placenta?  are  generally  in  close  apposition,  and 
become  fused  into  a  single  mass ;  the  cords,  separately  attached  to  each 
foetus,  not  infrequently  uniting  shortly  before  reaching  the  placental 
mass,  their  vessels  anastomosing  freely.  In  other  more  rare  instances 
both  foetuses  are  contained  in  a  common  amniotic  sac ;  but  as  the 
amnion  is  a  purely  foetal  membrane,  it  is  probable  that,  when  this 
arrangement  is  met  with,  the  originally  existing  septum  between  the 
amniotic  sacs  has  been  destroyed.  In  both  these  latter  cases  the  twins 
must  have  been  developed  from  a  single  ovule  containing  a  double 
germ,  and  Schroeder  states  that  they  are  then  always  of  the  same  sex, 
and  have  a  striking  similarity  to  each  other.  Dr.  Brunton1  has 
started  a  precisely  opposite  theory,  and  has  tried  to  prove  that  twins 
of  the  same  sex  are  contained  in  separate  bags  of  membrane,  while 
twins  of  opposite  sexes  have  a  common  sac.  He  says  that,  out  of 
twenty-five  cases  coming  under  his  observation,  in  fifteen  the  children 
contained  in  different  sacs  were  of  the  same  sex,  but  in  the  remaining 
ten,  in  which  there  was  only  one  sac,  they  were  of  opposite  sexes.  It 
is  difficult  to  believe  that  there  is  not  an  error  in  these  observations, 
since  twins  contained  in  a  single  amniotic  sac  do  not  occur  nearly  as 
often  as  ten  times  out  of  twenty-five  cases,  and  no  distinction  is  made 
between  a  common  chorion  with  two  amuions  and  a  single  chorion 
and  amnion.  The  facts  of  double  monstrosity  also  disprove  this 
view,  since  conjoined  twins  must  of  necessity  arise  from  a  single 

1  Obst.  Trans.,  1870,  vol.  xl.  p.  67. 


176  PREGNANCY. 

ovule  with  a  double  germ,  and  there  is  no  instance  on  record  in  which 
they  wrere  of  opposite  sexes. 

In  triplets  the  membranes  and  placentae  may  be  all  separate,  or,  as 
is  commonly  the  case,  there  is  one  complete  bag  of  membranes,  and  a 
second  having  a  common  choriou,  with  a  double  amnion.  It  is  prob- 
able, therefore,  that  triplets  are  generally  developed  from  two  ovules, 
one  of  which  contains  a  double  germ. 

Diagnosis  of  Multiple  Pregnancy. — It  is  comparatively  seldom 
that  twin  pregnancy  can  be  diagnosed  before  the  birth  of  the  first 
child,  and,  even  when,  suspicion  has  arisen,  its  indications  are  very 
defective.  There  is  generally  an  unusual  size  and  an  irregularity  of 
shape  of  the  uterus,  sometimes  even  a  distinct  depression  or  sulcus 
between  the  two  foatuses.  When  such  a  sulcus  exists  it  may  be  possi- 
ble to  make  out  parts  of  each  foetus  by  palpation  on  either  side  of  the 
uterus.  The  only  sign,  however,  on  which  the  least  reliance  can  be 
placed  is  the  detection  of  two  fostal  hearts.  If  two  distinct  pulsations 
are  heard  at  different  parts  of  the  uterus ;  if,  on  carrying  the  stetho- 
scope from  one  point  to  another,  there  is  an  interspace  where  pulsa- 
tions are  no  longer  audible,  or  when  they  become  feeble,  and  again 
increase  in  clearness  as  the  second  point  is  reached  ;  and,  above  all,  if 
we  are  able  to  make  out  a  difference  in  frequency  between  them,  the 
diagnosis  is  tolerably  safe.  It  must  be  remembered,  however,  that 
the  sounds  of  a  single  heart  may  be  heard  over  a  larger  space  than 
usual,  and  hence  a  possible  source  of  error.  Twin  pregnancy,  moreover, 
may  readily  exist  without  the  most  careful  auscultation  enabling  us  to 
detect  a  double  pulsation,  especially  if  one  child  lie  in  the  dorso- 
posterior  position,  when  the  body  of  the  other  may  prevent  the  trans- 
mission of  its  heart's  beat.  The  so-called  placental  souffle  is  generally 
too  diffuse  and  irregular  to  be  of  any  use  in  diagnosis,  even  when  it  is 
distinctly  heard  at  separate  parts  of  the  uterus. 

Superfbetation  and  Superfecundation. — Closely  connected  with 
the  subject  of  multiple  pregnancies  are  the  conditions  known  as  super- 
fecundation  and  superfcetation,  regarding  which  there  have  been  much 
controversy  and  difference  of  opinion. 

By  the  former  is  meant  the  fecundation,  at  or  near  the  same  period 
of  time,  of  two  separate  ovules  before  the  decidua  lining  the  uterus 
has  been  formed,  which  by  many  is  supposed  to  form  an  insuperable 
obstacle  to  subsequent  impregnation.  The  possibility  of  this  occur- 
rence has  been  incontestably  proved  by  the  class  of  cases  already 
referred  to,  in  which  the  same  woman  has  given  birth  to  twins  bearing 
evident  traces  of  being  the  offspring  of  fathers  of  different  races. 

By  superfcetation  is  meant  the  impregnation  of  a  second  ovule  when 
the  uterus  already  contains  an  ovum  which  has  arrived  at  a  consider- 
able degree  of  development.  The  cases  wrhich  are  supposed  to  prove 
the  possibility  of  this  occurrence  are  very  numerous.  They  are  those 
in  which  a  woman  is  delivered  simultaneously  of  fetuses  of  very  dif- 
ferent ages,  one  bearing  all  the  marks  of  having  arrived  at  term,  the 
other  of  prematurity  ;  or  those  in  which  a  woman  is  delivered  of  an 
apparently  mature  child,  and,  after  the  lapse  of  a  few  months,  of 
another  equally  mature.  The  possibility  of  superfoetation  is  strongly 


ABNORMAL    PREGNANCY.  177 

denied  by  many  practitioners  of  eminence,  and  explanations  are  given 
which  doubtless  seem  to  account  satisfactorily  for  a  large  proportion 
of  the  supposed  examples.  In  the  former  class  of  cases  it  is  supposed, 
with  much  probability,  that  there  is  an  ordinary  twin  pregnancy,  the 
development  of  one  foetus  being  retarded  by  the  presence  in  utero  of 
another.  That  this  is  not  an  uncommon  occurrence  is  certain,  and 
the  fact  has  been  already  alluded  to  in  treating  of  twin  pregnancy. 
In  cases  of  the  latter  kind  it  is  possible  that  some  of  them  may  be 
due  to  separate  impregnation  in  a  bilobed  uterus,  the  contents  of  one 
division  being  thrown  off  a  considerable  time  before  those  of  the  other. 
Numerous  authentic  examples  of  this  occurrence  are  recorded,  but  by 
far  the  most  remarkable  is  that  related  by  Dr.  Ross,  of  Brighton, 
which  has  been  already  referred  to  (p.  68).  In  this  case  the  patient 
had  previously  given  birth  to  many  children  without  any  suspicion  of 
her  abuornal  formation  having  arisen,  and,  had  it  not  been  detected 
by  Dr.  Ross,  the  case  might  fairly  enough  have  been  claimed  as  an 
indubitable  example  of  superfcetation. 

Making  every  allowance  for  these  explanations,  there  remains  a 
considerable  number  of  cases  which  it  is  very  difficult  to  account  for, 
except  on  the  supposition  that  the  second  child  has  been  conceived  a 
considerable  time  after  the  first.  Those  interested  in  the  subject  will 
find  a  large  number  of  examples  collected  in  a  valuable  paper  by  Dr. 
Bonnar,  of  Cupar.1  He  has  adopted  the  ingenious  plan  of  consulting 
the  records  of  the  British  peerage,  where  the  exact  date  of  the  birth  of 
successive  children  of  peers  is  given,  without,  of  course,  any  reasonable 
possibility  of  error,  and  he  has  collected  numerous  examples  of  births 
rapidly  succeeding  each  other  which  are  apparently  inexplicable  on 
any  other  theory.  In  one  case  he  cites,  a  child  was  born  September 
12,  1849,  and  the  mother  gave  birth  to  another  on  January  24,  1850, 
after  an  interval  of  only  127  days.  Subtracting  from  that  14  days, 
which  Dr.  Bonnar  assumes  to  be  the  earliest  possible  period  at  which 
a  fresh  impregnation  can  occur  after  delivery,  we  reduce  the  gestation 
to  113  days — that  is,  to  less  than  four  calendar  months.  As  both 
these  children  survived,  the  second  child  could  not  possibly  have  been 
the  result  of  a  fresh  impregnation  after  the  birth  of  the  first;  nor  could 
the  first  child  have  been  a  twin  prematurely  delivered ;  for,  if  so,  it 
must  have  only  reached  rather  more  than  the  fifth  month,  at  which 
time  its  survival  would  have  been  impossible. 

Besides  the  numerous  examples  of  cases  of  this  kind  recorded  in 
most  obstetric  works,  there  are  one  or  two  of  miscarriage  in  the  early 
months,  in  which,  in  addition  to  a  foetus  of  four  or  five  months'  growth, 
a  perfectly  fresh  ovum  of  not  more  than  a  month's  development  was 
thrown  off.  One  such  case  was  shown  at  the  Obstetrical  Society  in 
1862,  which  was  reported  on  by  Drs.  Harley  and  Tanner,  who  stated 
that  in  their  opinion  it  was  an  example  of  superfoetation.  A  still  more 
conclusive  case  is  recorded  by  Tyler  Smith.2  "A  young  married  woman, 
pregnant  for  the  first  time,  miscarried  at  the  end  of  the  fifth  month, 
and  some  hours  afterward  a  small  clot  was  discharged,  enclosing  a 

1  Edin.  Med.  Journ.,  1864-65.  2  Manual  of  Obstetrics,  p.  112. 


178 


PREGNANCY. 


perfectly  healthy  ovum  of  about  one  month.  There  were  no  signs  of 
a  double  uterus"  in  this  case.  The  patient  had  menstruated  regularly 
during  the  time  she  had  been  pregnant."  This  case  is  of  special  inter- 
est from  the  fact  of  the  patient  having  menstruated  during  pregnancy 
— a  circumstance  only  explicable  on  the  same  anatomical  grounds 
which  render  superfcetation  possible.  So  far  as  I  know,  it  is  the  only 
instance  in  which  the  coincidence  of  superfoetation  and  menstruation 
during  early  pregnancy  has  been  observed. 

The  objections  to  the  possibility  of  superfoetation  are  based  on  the 
assumptions  that  the  decidua  so  completely  fills  up  the  uterine  cavity 
that  the  passage  of  the  spermatozoa  is  impossible ;  that  their  passage 
is  prevented  by  the  mucous  plug  which  blocks  up  the  cervix;  and 


FIG.  si. 


Illustrating  the  cavity  between  the  decidua  vera  and  the  decidua  reflexa  during  the  early 
months  of  pregnancy.    (After  COSTE.) 

that  when  impregnation  has  taken  place  ovulation  is  suspended.  It 
is,  however,  certain  that  none  of  these  is  an  insuperable  obstacle  to  a 
second  impregnation.  The  first  was  originally  based  on  the  older  and 
erroneous  view  which  considered  the  decidua  to  be  an  exudation  lining 
the  entire  uterine  cavity,  and  sealing  up  the  mouths  of  the  Fallopian 
tubes  and  the  aperture  of  the  internal  os  uteri.  The  decidua  reflexa, 
however,  does  not  come  into  apposition  with  the  decidua  vera  until 
about  the  eighth  week  of  pregnancy,  and,  therefore,  until  that  time 
there  is  a  free  space  between  the  two  membranes  through  which  the 
spermatozoa  might  pass  to  the  open  mouth  of  the  Fallopian  tube,  and 
in  which  a  newly  impregnated  ovule  might  graft  itself.  A  reference 
to  the  accompanying  figure  of  a  pregnancy  in  the  third  mouth,  copied 
from  Coste's  work,  will  readily  show  that,  as  far  as  the  decidua  is  con- 


ABNORMAL    PREGNANCY.  179 

cerned,  there  is  no  mechanical  obstacle  to  the  descent  and  lodgment  of 
another  impregnated  ovule  (Fig.  81).  Then,  as  regards  the  plug  of 
mucus,  it  is  pretty  certain  that  this  is  in  no  way  different  from  the 
mucus  filling  the  cervix  in  the  non-pregnant  state,  which  offers  no 
obstacle  at  all  to  the  passage  of  the  spermatozoa.  Lastly,  respecting 
the  cessation  of  ovulation  during  pregnancy,  this,  no  doubt,  is  the 
rule,  and  probably  satisfactorily  explains  the  rarity  of  superfcetation. 
There  are,  however,  a  sufficient  number  of  authenticated  cases  of  men- 
sfruation  during  pregnancy,  to  prove  that  ovulation  is  not  always 
absolutely  in  abeyance ;  and,  as  long  as  it  occurs,  there  is  unquestion- 
ably no  positive  mechanical  obstruction,  at  least  in  the  early  months 
of  pregnancy,  in  the  \vay  of  the  impregnation  and  lodgment  of  the 
ovules  that  are  thrown  off.  The  reasonable  conclusion,  therefore, 
seems  to  be  that,  although  a  large  majority  of  the  supposed  cases  are 
explicable  in  other  ways,  it  cannot  be  admitted  that  superfoatation  is 
either  physiologically  or  mechanically  impossible. 

Extra-uterine  Pregnancy. — The  most  important  of  the  abnormal 
varieties  of  pregnancy,  if  we  consider  the  serious  and  very  generally 
fatal  results  attending  it,  is  the  so-called  extra-uterine  gestation,  or 
ectopic  pregnancy,  as  some  prefer  to  call  it,  which  consists  in  the  arrest 
and  development  of  the  ovum  outside  the  cavity  of  the  uterus.  Of 
late  years  this  subject  has  received  much  well-merited  attention,  which, 
it  is  to  be  hoped,  may  lead  to  the  establishment  of  definite  rules  for 
the  management  of  this  most  anxious  and  dangerous  class  of  cases. 

Extra-uterine  gestation  has  hitherto  been  generally  divided  into 
three  chief  classes,  tubal,  abdominal,  and  ovarian,  according  to  the 
position  in  which  the  fecundated  ovum  is  developed.  It  is  to  be  noted 
that  Lawson  Tait,1  who  has  an  unrivalled  experience  in  this  subject, 
considers  all  extra-uterine  pregnancies  to  be  primarily  tubal,  the  other 
varieties  being  developments  after  rupture,  as  will  be  subsequently 
explained.  This  view  is  strongly  upheld  by  Bland  Button,2  who  main- 
tains that  "all  forms  of  extra-uterine  gestation  pass  their  primary 
stage  in  the  Fallopian  tube."  This  opinion,  although  it  is  receiving 
an  increasing  number  of  supporters,  cannot  as  yet  be  admitted  as  con- 
clusively proved,  and,  therefore,  it  seems  best  to  retain,  provisionally 
at  least,  the  ordinary  classification. 

Classification. — The  following  classes  are  generally  admitted :  1st, 
and  most  common  of  all,  tubal  gestation,  and  as  varieties  of  this, 
although  by  some  made  into  distinct  classes,  (a)  interstitial,  (6)  tubo- 
ovarian  gestation,  and  (c)  sub-peritoneo-pelvie,  or  intra-ligamentous.  In 
the  first  of  these  subdivisions  the  ovum  is  arrested  in  the  part  of  the 
Fallopian  tube  that  is  situated  in  the  substance  of  the  uterine  parietes; 
in  the  second,  at  or  near  the  fimbriated  extremity  of  the  tube — so  that 
part  of  its  cyst  is  formed  by  the  tube  and  part  by  the  ovary ;  in  the 
third,  an  originally  tubal  pregnancy  develops  into  the  broad  ligament, 
and  continues  this  development  beneath  the  peritoneum  of  the  pelvic 
floor.  2d.  Abdominal  gestation,  in  which  an  impregnated  ovum, 
instead  of  finding  its  way  into  the  tube,  falls  into  the  peritoneal  cavity, 

1  Lectures  on  Ectopic  Pregnancy,  1S88. 

8  Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes,  1891. 


180  PREGNANCY. 

and  there  becomes  attached  and  developed  ;  this  is  the  so-called  "  pri- 
mary "  abdominal  pregnancy,  the  possibility  of  which  is  denied  by 
many  recent  writers ;  or  the  so-called  "  secondary "  abdominal  gesta- 
tion, in  which  an  extra-uterine  pregnancy,  originally  tubal,  becomes 
ventral,  through  rupture  of  its  cysts  and  escape  of  its  contents  into  the 
abdominal  cavity ;  or  in  which  an  intra-ligamentous  pregnancy  con- 
tinues to  develop  until  it  lifts  up  the  abdominal  peritoneum,  and  forms 
a  purely  extra-peritoneal  variety  of  abdominal  gestation.  This  has 
been  called  by  Hart  and  Carter  sub-peritoneo-abdominal.1  3d.  Ova- 
rian gestation,  the  existence  of  which  is  denied  by  many  writers  of 
eminence,  such  as  Velpeau  and  Arthur  Farre,  while'  it  is  maintained 
by  others  of  equal  celebrity,  such  as  Kiwisch,  Coste,  and  Hecker.  It 
must  be  admitted  that  it  is  extremely  difficult  to  understand  how  an 
ovarian  pregnancy,  in  the  strict  sense  of  the  word,  can  occur,  for  it 
implies  that  the  ovule  has  become  impregnated  before  the  laceration  of 
the  Graafian  follicle,  through  the  coats  of  which  the  spermatozoa  must 
have  passed.  Coste,  indeed,  believes  that  this  frequently  happens; 
but,  while  spermatozoa  have  been  detected  on  the  surface  of  the  ovary, 
their  penetration  into  the  Graafian  follicle  has  never  been  demonstrated. 
Farre  has  also  clearly  shown  that  in  many  cases  of  supposed  ovarian 
pregnancy  the  surrounding  structures  were  so  altered  that  it  was  im- 
possible to  trace  their  exact  origin  and  to  say  to  a  certainty  that  the 
foetus  was  really  within  the  substance  of  the  ovary.  Kiwisch  gives  a 
reasonable  explanation  of  these  cases  by  supposing  that  sometimes  the 
Graafian  follicle  may  rupture,  but  that  the  ovule  may  remain  within 
it  without  being  discharged.  Through  the  rent  in  the  walls  of  the 
follicle  the  spermatozoa  may  reach  and  impregnate  the  ovule,  which 
may  develop  in  the  situation  in  which  it  has  been  detained.  The  sub- 
ject has  been  ably  considered  by  Puech,2  who  admits  two  varieties  of 
ovarian  pregnancy,  according  as  the  foetus  has  developed  in  a  vesicle 
Avhich  has  remained  open,  or  in  one  which  has  closed  immediately  after 
fecundation.  He  considers  that  most  cases  of  so-called  ovarian  preg- 
nancy are  either  dermoid  cysts,  ovario-tubal  pregnancies,  or  abominal 
pregnancies  in  Avhich  the  placenta  is  attached  to  the  ovary,  and  that 
even  in  the  rare  cases  of  true  ovarian  pregnancies  the  progress  and 
results  do  not  differ  from  those  of  abdominal  pregnancy.  While, 
therefore,  it  is  impossible  to  deny  the  existence  of  ovarian  pregnancy, 
it  must  be  considered  to  be  a  very  rare  and  exceptional  variety,  the 
existence  of  which  has  never  been  actually  proved,  which,  as  far  as 
treatment  and  results  are  concerned,  does  not  differ  from  tubular  or 
abdominal  gestation.  4th.  There  are  two  rare  varieties  in  which  an 
ovum  is  developed  either  in  the  supplementary  horn  of  a  bi-lobed 
uterus,  or  in  a  hernial  sac. 

For  the  sake  of  clearness,  we  may  place  these  varieties  of  extra- 
uterine  gestation  in  the  following  tabular  form  : 

1.   Tubal— 

(a)  Interstitial,  (6)  Tubo-ovarian,  (c)  Sub-peritoneo-pelvic. 

i  "  Sectional  Anatomy  of  Advanced  Extra-uterine  Gestation,"  Edin.  Med,  Journ.,  October,  1887. 
»  Annal.  de  Gynec.,  1878,  torn.  x.  p.  102. 


ABNORMAL    PREGNANCY.  181 

2.  Abdominal — 

(a)  Primary  (?),  (6)  Secondary. 

3.  Ovarian  (?). 

4.  In  bi-lobed  uterus,  hernial,  etc. 

Causes. — The  etiology  of  extra-uterine  fcetation  in  any  individual 
case  must  necessarily  be  almost  always  obscure.  Broadly  speaking,  it 
may  be  said  that  extra-uterine  fcetation  may  be  produced  by  any  con- 
dition which  prevents  or  renders  difficult  the  passage  of  the  ovule  to 
the  uterus  while  it  does  not  prevent  the  access  of  the  spermatozoa  to 
the  ovule.  Thus  inflammatory  thickening  of  the  coats  of  the  Fallopian 
tubes,  by  lessening  their  calibre,  but  not  sufficiently  so  as  to  prevent 
the  passage  of  the  spermatozoa,  may  interfere  with  the  movements 
of  the  tube  whicli  propel  the  ovum  forward,  and  so  cause  its  arrest. 
Various  morbid  conditions,  such  as  inflammatory  adhesions,  from  old- 
standing  peritonitis,  pressing  on  the  tube ;  obstruction  of  its  calibre 
by  inspissated  mucus  or  small  polypoid  growths ;  the  pressure  of 
uterine  or  other  tumors,  and  the  like,  are  supposed  to  have  a  similar 
effect.  Tait1  believes  that  the  most  important  cause  is  chronic  sal- 
pingitis,  leading  to  destruction  of  the  epithelium  lining  the  tubes. 
The  function  of  the  epithelial  cilia  being  to  favor  the  progress  of  the 
ovum  toward  the  uterus,  when  they  no  longer  exist  the  mucous  lining 
of  the  tubes  is  reduced  to  a  condition  similar  to  that  of  the  endo- 
metrium,  and  the  ovum  is  apt  to  be  arrested  in  transitu.  Bland 
Button2  admits  this  to  be  a  possible  although  as  yet  an  unproved 
explanation.  The  fact  that  extra-uterine  pregnancies  occur  most  fre- 
quently in  multipart,  and  comparatively  rarely  in  women  under  thirty 
years  of  age,  tends  to  show  that  these  conditions,  which  are  clearly 
more  likely  to  be  met  with  in  such  women  than  in  young  primiparae, 
have  considerable  influence  in  their  causation.  A  curiously  large 
proportion  of  cases  occur  in  women  who  have  either  been  previously 
altogether  sterile,  or  in  wrhom  a  long  interval  of  time  has  elapsed  since 
their  last  pregnancy.  The  disturbing  effects  of  fright,  either  during 
coition  or  a  few  days  afterward,  have  been  insisted  on  by  many  authors 
as  a  possible  cause.  Numerous  cases  of  this  kind  are  recorded  ;  and, 
although  the  influence  of  emotion  in  the  production  of  this  condition 
is  not  susceptible  of  proof,  it  is  not  difficult  to  imagine  that  spasms  of 
the  Fallopian  tubes  might  be  produced  in  this  wray,  whicli  would  either 
interfere  with  the  passage  of  the  ovum,  or  direct  it  into  the  abdominal 
cavity.  The  occurrence  of  abdominal  pregnancy  is  probably  less 
difficult  to  account  for  if  we  admit,  with  Coste,  that  the  ovule  may 
become  impregnated  on  the  surface  of  the  ovary  itself,  for  there  must 
be  very  many  conditions  whicli  prevent  the  proper  adaptation  of  the 
fimbriated  extremity  of  the  tube  to  the  surface  of  the  ovary,  and  failing 
this  the  ovum  must  of  necessity  drop  into  the  abdominal  cavity. 
Kiwisch  has  pointed  out  that  this  is  particularly  apt  to  occur  when 
the  Graafian  follicle  develops  on  the  posterior  surface  of  the  ovary ; 
and,  indeed,  it  is  probable  that  it  may  be  of  common  occurrence,  and 
that  the  comparative  rarity  of  abdominal  pregnancy  is  due  to  the  diffi- 

i  Op.  cit.,  p.  4.  *  Op.  cit,  p.  309. 


182  PREGNANCY. 

culty  with  which  the  impregnated  ovule  engrafts  itself  on  the  sur- 
rounding viscera.  Impregnation  may  actually  occur  in  the  abdominal 
cavity  itself,  of  which  Keller 1  relates  a  remarkable  instance.  In  this 
case  Koeberle  had  removed  the  body  of  the  uterus  and  part  of  the 
cervix,  leaving  the  ovaries.  In  the  portion  of  the  cervix  that  remained 
there  was  a  fistulous  aperture  opening  into  the'  abdominal  cavity, 
through  which  semen  passed  and  produced  an  abdominal  gestation. 
Several  curious  cases  are  also  recorded,  which  have  given  rise  to  a 
good  deal  of  discussion,  in  which  a  tubal  pregnancy  existed  while  the 
corpus  luteum  was  on  the  opposite  side  (Fig.  82).  The  most  probable 

FIG.  82. 


Tubal  pregnancy,  with  the  corpus  luteum  in  the  ovary  of  the  opposite  side.    The  decidua  is 
represented  in  the  process  of  detachment  from  the  uterine  cavity. 

explanation,  however,  is  that  the  fimbriated  extremity  of  the  tube  in 
which  the  ovum  was  found  had  twisted  across  the  abdominal  cavity 
and  grasped  the  opposite  ovary,  in  this  way,  perhaps,  producing  a 
flexion  which  impeded  the  progress  of  the  ovum  it  had  received  into 
its  canal.  Tyler  Smith  suggested  that  such  cases  might  be  explained 
by  supposing  that  the  ovum,  after  reaching  the  uterus,  failed  to  graft 
itself  in  the  mucous  membrane,  but  found  its  way  into  the  opposite 
Fallopian  tube.  Kussmaul2  thinks  that  such  a  passage  of  the  ovum 
across  the  uterine  cavity  may  be  caused  by  muscular  contraction  of 
the  uterus,  occurring  shortly  after  conception,  squeezing  the  yet  free 
ovum  upward  toward  the  opening  of  the  opposite  tube,  and  possibly 
into  the  tube  itself. 

The  history  and  progress  of  cases  of  extra-uterine  pregnancy  are 
materially  different  according  to  their  site,  and  it  is,  therefore,  neces- 
sary to  examine  its  varieties  in  detail. 

Tubal  Pregnancies. — When  the  ovum  is  arrested  in  any  part  of 
the  Fallopian  tube  the  chorion  soon  commences  to  develop  villi,  just 
as  in  ordinary  pregnancy,  which  engraft  themselves  into  the  mucous 
lining  of  the  tube,  and  fix  the  ovum  in  its  new  position.  The  mucous 
membrane  becomes  hypertrophied,  much  in  the  same  way  as  that  of  the 

1  Des  Grossesses  extra-utertnes,  Paris,  1872. 

2  Mon.  f.  Geburt.,  1862.  Bd.  xx.  8.  295. 


ABNORMAL    PREGNANCY. 


183 


FIG.  83. 


uterus  under  similar  circumstances,  so  that  it  becomes  developed  into  a 
sort  of  pseudo-decidua,  the  uterine  extremity  of  which  has  been  observed 
to  be  open  and  in  communication 
with  the  lining  membrane  of  the 
uterus.1  Inasmuch,  however,  as  the 
mucous  coat  of  the  tubes  is  not  fur- 
nished with  tubular  glands,  a  true 
decidua  can  scarcely  be  said  to  exist ; 
nor  is  there  any  growth  of  mem- 
brane around  the  ovum  analogous 
to  the  decidua  reflexa.  The  ovum 
is,  therefore,  comparatively  speak- 
ing, loosely  attached  to  its  abnormal 
situation,  and  hence  hemorrhage  from 
laceration  of  the  chorion  villi  can 
very  readily  take  place.  This  leads 
to  extravasation  of  blood  between 
the  villi,  and  it  is  often  the  determining  cause  of  rupture,  in  conse- 
quence of  the  sudden  increase  in  size  of  the  tube  contents.  Should 
rupture  not  occur  the  ovum  may  be  transformed  into  a  fleshy  mole, 
analogous  to  the  uterine  mole.  And  this  is,  doubtless,  the  origin  of 
many  cases  of  the  so-called  "  hsemato-salpinx."  The  dependence  of 
this  on  pregnancy  may  generally  be  proved  by  the  tube  contents  show- 
ing chorionic  villi  on  microscopical  examination  (Fig.  83). 

Tubal  Abortion. — In  some  such  cases  the  mole  may  afterward 
escape  by  rupture  into  the  folds  of  the  broad  ligament,  producing  a 

FIG.  84. 


Microscopical  appearances  of  chorionie 
villi  in  transverse  section  from  a  tubal  mole 
—low  magnification.  (After  BLAND  SUTTON.) 


Tubal  pregnancy.    (From  a  specimen  in  the  Museum  of  King's  College.) 
1  L.  Bandl:  Billroth's  Handbuch  der  Frauenkrankheiten. 


184 


PREGNANCY. 


heematocele,    and    these    conditions    have   been    described   as    "  tubal 
abortion." 

It  is  seldom  that  any  development  of  the  chorion  villi  into  distinct 
placental  structure  is  observed ;  this  is  probably  owing  to  the  fact  that 
laceration  and  death  generally  occur  before  the  period  at  which  the 
placenta  is  normally  formed.  The  muscular  coat  of  the  tube  soon 
becomes  hypertrophied,  and  as  the  size  of  the  ovum  increases  the 
fibres  are  separated  from  each  other,  so  that  the  ovum  protrudes  at 
certain  points  through  them,  and  at  these  it  is  only  covered  by  the 
stretched  and  attenuated  mucous  and  peritoneal  coats  of  the  tube.  At 
this  time  the  tubal  pregnancy  forms  a  smooth  oval  tumor,  which,  as  a 
rule,  has  not  formed  any  adhesions  to  the  surrounding  structures 
(Fig.  84).  The  part  of  the  tube  unoccupied  by  the  ovum  may  be 
found  unaltered,  and  permeable  in  both  directions;  or,  more  frequently, 
it  becomes  so  stretched  and  altered  that  its  canal  cannot  be  detected. 
Most  frequently  it  is  that  part  of  the  tube  nearest  the  uterus  which 
cannot  be  made  out.  Button  states  that  by  the  eighth  week  the  abdom- 
inal extremity  of  the  tube  becomes  obliterated  by  the  protrusion  of  a 
ring  of  peritoneum  around  it,  which  gradually  becomes  occluded,  and 
so  hermetically  closes  the  opening. 

FIG.  85. 


Interstitial  or  tubo-uterine  pregnancy.    (Guy's  Hospital  Museum.    After  BLAND  SUTTON.) 


Condition  of  the  Uterus. — The  condition  of  the  uterus  in  this, 
as  in  other  forms  of  extra-uterine  pregnancy,  has  been  the  subject  of 

It  is  now  universally  admitted  that  the  uterus 


considerable  discussion. 


ABNORMAL    PREGNANCY.  185 

undergoes  a  certain  amount  of  sympathetic  engorgement,  the  cervix 
becomes  softened,  as  in  natural  pregnancy,  and  the  mucous  membrane 
develops  into  a  true  decidua.  In  many  cases  the  decidua  is  found  on 
post-mortem  examination,  in  others  it  is  not ;  and  hence  the  doubts 
that  some  have  expressed  as  to  its  existence.  The  most  reasonable 
explanation  of  its  absence  is  that  given  by  Duguet,1  who  has  shown 
that  it  is  far  from  uncommon  for  the  uterine  decidua  to  be  thrown  oif 
en  masse  during  the  hemorrhagic  discharges  which  so  frequently  pre- 
cede the  fatal  issue  of  extra-uterine  gestation. 

Interstitial  and  False  Ovarian  Pregnancy. — When  the  ovum  is 
arrested  in  that  portion  of  the  tube  passing  through  the  uterus,  in 
so-called  interstitial  pregnancy  (Fig.  85)  the  muscular  fibres  of  the 
uterus  become  stretched  and  distended,  and  form  the  outer  covering 
of  the  ovum.  In  this  case  rupture  is  delayed  to  a  later  date  than  in 
tubal  pregnancy,  but,  when  it  occurs,  hemorrhage  is  greater,  in  con- 
sequence of  the  thickness  of  the  gestation  sac,  and  the  fatal  issue  is 
more  certain  and  rapid.  When,  on  the  other  hand,  the  site  of  arrest 
is  in  the  fimbriated  extremity  of  the  tube,  the  containing  cyst  is  formed 
partly  of  the  fimbrire  of  the  tube,  partly  of  ovarian  tissue ;  hence  it 
is  much  more  distensible,  and  the  pregnancy  may  continue  without 
laceration  to  a  more  advanced  period,  or  even  to  term,  so  that  when 
the  ovum  is  placed  in  this  situation  the  case  much  more  nearly  resem- 
bles one  of  abdominal  pregnancy. 

Progress  and  Termination. — The  termination  of  tubal  pregnancy, 
in  the  immense  majority  of  cases,  is  death,  produced  by  laceration 
giving  rise  either  to  internal  hemorrhage  or  to  subsequent  intense 
peritonitis.  Rupture  usually  occurs  at  an  early  period  of  pregnancy, 
most  generally  from  the  fourth  to  the  twelfth  week,  rarely  later. 
However,  a  few  instances  are  recorded  in  which  it  did  not  take  place 
until  the  fourth  or  fifth  month,  and  Saxtorph  and  Spiegelberg  have 
recorded  apparently  authentic  cases  in  which  the  pregnancy  advanced 
to  term  without  laceration ;  these  were,  however,  probably  examples 
of  the  sub-peritonco-pelvic  or  abdominal  varieties.  It  is  generally 
effected  by  distention  of  the  tube,  which  at  last  yields  at  the  point 
which  is  most  stretched ;  and  sometimes  it  seems  to  be  hastened  or 
determined  by  accidental  circumstances,  such  as  a  blow  or  fall,  or  the 
excitement  of  sexual  intercourse. 

Symptoms  of  Rupture. — The  symptoms  accompanying  rupture 
are  those  of  intense  collapse,  often  associated  with  severe  abdominal 
pain,  produced  by  the  laceration  of  the  cyst.  The  patient  will  be 
found  deadly  pale,  with  a  small,  thready,  and  almost  imperceptible 
pulse,  perhaps  vomiting,  but  with  mental  faculties  clear.  If  the 
hemorrhage  be  considerable,  she  may  die  without  any  attempt  at 
reaction.  Sometimes,  however — and  this  generally  occurs  in  cases  in 
which  the  tube  tears,  the  ovum  remaining  intact — the  hemorrhage 
may  cease  on  account  of  the  ovum  protruding  through  the  aperture 
and  acting  as  a  plug.  The  patient  may  then  imperfectly  rally,  to  be 
again  prostrated  by  a  second  escape  of  blood,  which  proves  fatal.  If 

i  Annales  de  Gynecologic,  1874,  torn.  1.  p.  269. 


186 


PREGNANCY. 


the  loss  of  blood  is  not  of  itself  sufficient  to  cause  death  from  shock 
and  antenna,  the  fatal  issue  is  generally  only  postponed,  for  the  effused 
blood  soon  sets  up  a  violent  general  peritonitis,  which  rapidly  carries 
off  the  patient.  This  is  the  general  course  of  events  in  the  most 
common  class  of  cases,  in  which  the  rupture  involves  the  peritoneal 
surface  of  the  tube.  The  hemorrhage  then  takes  place  directly  into 
the  peritoneal  cavity,  and,  unless  cceliotomy  is  performed,  is  most 
usually  fatal. 


FIG. 


Extra-uterine  pregnancy  at  term  of  the  secondary  abdominal  variety.    (After  a  case  of 
DR.  A.  SIBLEY  CAMPBELL'S.) 

In  the  minority  of  cases  of  rupture,  the  proportion  being  given  by 
Button  as  1  to  3,  the  laceration  takes  place  in  that  part  of  the  tube 
which  is  not  covered  with  peritoneum,  that  is,  the  under  surface  of 
the  middle  third  of  the  tube.  The  blood  then  escapes  into  the  con- 
nective tissue  of  the  broad  ligament,  and  is  consequently  extra- 
peritoneal.  The  space  into  which  the  blood  can  pour  is  much  more 
limited  than  in  the  former  case,  and  the  results  are  less  uniformly 
disastrous.  If  the  ovum  and  the  patient  both  survive  the  immediate 
rupture,  the  former  continues  to  grow,  and  the  case  is  transformed  into 
one  of  sub-peritoneo-pelvic  gestation.  The  case  is  then  subjected  to 
the  rules  of  treatment  presently  to  be  discussed  when  considering 
secondary  abdominal  pregnancy.  (Fig.  86.) 


ABNORMAL    PREGNANCY.  187 

Diagnosis. — The  possibility  of  diagnosing  tubal  gestation  before 
rupture  occurs  is  a  question  of  great  and  increasing  interest,  from  the 
fact  that,  could  its  existence  be  ascertained,  \ve  might  very  fairly  hope 
to  avert  the  almost  certainly  fatal  issue  which  is  awaiting  the  patient. 
Unfortunately,  the  symptoms  of  tubal  pregnancy  are  always  obscure, 
and  too  often  death  occurs  without  the  slightest  suspicion  as  to  the 
nature  of  the  case  having  arisen.  In  the  first  place  it  is  to  be  observed 
that  all  the  usual  sympathetic  disturbances  of  pregnancy  exist:  the 
breasts  enlarge,  the  areolse  darken,  and  morning  sickness  is  present. 
There  is  also  an  arrest  of  menstruation ;  but,  after  the  absence  of  one 
or  more  periods,  there  is  often  an  irregular  hemorrhagic  discharge. 
This  is  an  important  symptom,  the  value  of  which  in  indicating  the 
existence  of  tubal  pregnancy  has  of  late  years  been  much  dwelt  upon 
by  various  authors,  both  in  this  country  and  abroad.  It  may  probably 
be  attributed  to  partial  detachment  of  the  chorion  villi,  produced  by 
the  ovum  growing  out  of  proportion  to  the  tube  in  which  it  is  con- 
tained. Whether  this  is  the  correct  explanation  or  not,  it  is  a  fact 
that  irregular  hemorrhage  very  generally  precedes  the  laceration  for 
several  days  or  more.  Associated  with  the  hemorrhage  there  may 
occasionally  be  found  shreds  of  the  decidual  lining  of  the  uterus,  the 
presence  of  which  would  materially  aid  the  diagnosis.  Accompanying 
this  hemorrhage  there  is  almost  always  more  or  less  abdominal  pain, 
produced  by  the  stretching  of  the  tissues  in  which  the  ovum  is  placed, 
and  this  is  sometimes  described  as  being  of  very  intense  and  crampy 
character.  If,  then,  we  meet  with  a  case  in  which  the  symptoms  of 
early  pregnancy  exist,  in  which  there  are  irregular  losses  of  blood, 
possibly  discharge  of  membranous  shreds,  and  abdominal  pain,  a  care- 
ful examination  should  be  insisted  on,  and  then  the  true  nature  of  the 
case  may  possibly  be  ascertained.  Should  extra-uterine  fcetation  exist, 
we  should  expect  to  find  the  uterus  somewhat  enlarged,  and  the  cervix 
softened,  as  in  early  pregnancy,  but  both  these  changes  are  doubtless 
generally  less  marked  than  in  normal  pregnancy.  This  fact  of  itself, 
however,  is  of  little  diagnostic  value,  for  slight  differences  of  this  kind 
must  always  be  too  indefinite  to  justify  a  positive  opinion. 

The  existence  of  a  peri-uterine  tumor,  rounded  or  oval  in  outline, 
and  producing  more  or  less  displacement  of  the  uterus,  in  the  direction 
opposite  to  that  in  which  the  tumor  is  situated,  may  point  to  the  exist- 
ence of  tubular  fetation.  By  bimauual  examination,  one  hand  de- 
pressing the  abdominal  wall,  while  the  examining  finger  of  the  other 
acts  in  concert  with  it  either  through  the  vagina  or  rectum,  the  size 
and  relations  of  the  growth  may  be  made  out.  There  are  various 
conditions  which  give  rise  to  very  similar  physical  signs,  such  as  small 
ovarian  or  fibroid  growths,  or  the  effusion  of  blood  around  the  uterus ; 
and  the  differential  diagnosis  must  always  be  very  difficult  and  often 
impossible.  A  curious  example  of  the  difficulty  of  diagnosis  is  re- 
corded by  Joulin,  in  which  Huguier  and  six  or  seven  of  the  most 
skilled  obstetricians  of  Paris  agreed  on  the  existence  of  extra-uterine 
pregnancy,  and  had,  in  consultation,  sanctioned  an  operation,  when 
the  case  terminated  by  abortion,  and  proved  to  be  a  natural  pregnancy. 
The  use  of  the  uterine  sound,  which  might  aid  in  clearing  up  the  case, 


188  PEEGNANCY. 

is  necessarily  contra-indicated  unless  uterine  gestation  is  certainly  dis- 
proved. Hence  it  must  be  admitted  that  positive  diagnosis  must 
always  be  very  difficult.  So  that  the  most  we  can  say  is,  that  when 
the  general  signs  of  early  pregnancy  are  present,  associated  with  the 
other  symptoms  and  signs  alluded  to,  the  suspicion  of  tubal  preg- 
uaucy  may  be  sufficiently  strong  to  justify  us  in  taking  such  action  as 
may  possibly  spare  the  patient  the  necessarily  fatal  consequence  of 
rupture. 

Treatment. — If  the  diagnosis  were  quite  certain,  the  removal  of  the 
entire  Fallopian  tube  and  its  contents  by  abdominal  section  M'ould  be 
quite  justifiable,  and  would  neither  be  more  difficult  nor  more  danger- 
ous than  ovariotomy ;  for,  at  this  stage  of  extra-uterine  foetation,  there 
are  no  adhesions  to  complicate  the  operation.  This  operation  has  been 
performed  in  many  cases  with  a  most  happy  result,  and  there  can  be 
no  doubt  that  in  the  hands  of  an  operator  sufficiently  expert  in  abdom- 
inal surgery,  it  is  the  proper  course  to  adopt,  whenever  the  symptoms 
are  sufficiently  well  marked  to  indicate  its  necessity. 

It  is  to  be  observed,  however,  that  the  uncertainty  in  the  diagnosis 
in  cases  of  this  kind  is  very  great,  and  it  requires  a  good  deal  of  ex- 
perience and  self-reliance  to  enable  the  practitioner  to  adopt  so  radical 
a  procedure.  It  is  not  surprising,  therefore,  that  many  expedients 
have  been  suggested  and  tried  for  arresting  the  growth  of  the  ovum, 
and  thus  leaving  it  quiescent  in  the  tube.  Many  cases  have  been 
recorded  in  which  the  issue  has  been  supposed  to  be  satisfactory. 
Whether  they  were  so  in  fact,  or  whether  the  diagnosis  was  erroneous, 
as  the  opponents  of  such  procedures  are  so  apt  to  suggest,  cannot,  of 
course,  be  proved  in  the  nature  of  things.  Such  procedures  are  char- 
acterized by  Tait  as  "mere  nonsense,"1  and  by  Sutton  as  so  unsatis- 
factory as  not  to  merit  discussion.  It  must  be  fully  admitted  that 
coeliotomy  in  competent  hands  is  infinitely  more  satisfactory,  and  it 
may  be  confidently  recommended  in  every  case  in  which  the  diagnosis 
is  sufficiently  plain.  There  will  always,  however,  be  a  certain  number 
of  cases  in  which,  either  from  the  surroundings,  the  want  of  assistance 
or  instruments,  or  of  sufficient  surgical  aptitude  on  the  part  of  the 
medical  attendant,  such  radical  measures  cannot  be  adopted,  and,  there- 
fore, the  methods  referred  to  seem  worthy  of  consideration. 

Dr.  Thomas,  of  New  York,3  has  recorded  a  most  instructive  case,  in 
which  he  saved  the  life  of  the  patient  by  a  bold  operation.  The  nature 
of  the  case  was  rendered  pretty  evident  by  the  signs  above  described, 
and  Thomas  opened  the  cyst  from  the  vagina  by  a  platinum  knife, 
rendered  incandescent  by  a  galvanic  battery,  by  which  means  he  hoped 
to  prevent  hemorrhage.  Through  the  opening  thus  made  he  removed 
the  foetus.  In  subsequently  attempting  to  remove  the  placenta  very 
violent  hemorrhage  took  place,  which  was  only  arrested  by  injecting 
the  cyst  with  a  solution  of  persulphate  of  iron.  The  remains  of  the 
placenta  subsequently  came  away  piecemeal,  after  an  attack  of  septi- 
caemia, which  was  kept  within  bounds  by  freely  washing  out  the  cyst 
with  antiseptic  lotion,  the  patient  eventually  recovering.  Should  this 

1  Op.  cit.,  p.  53. 

9  New  York  Med.  Journ.,  1875,  vol.  xxi.  p.  561. 


ABNORMAL    PREGNANCY.  189 

operation  be  resorted  to,  it  would  be  better  not  to  remove  the  placenta, 
but  to  plug  the  gestation  sac  Avith  antiseptic  gauze,  frequently  changed, 
and  trust  to  antiseptic  injections  and  thorough  drainage  to  prevent 
septic  mischief.  This  procedure  has  not,  so  far  as  I  know,  been  again 
adopted;  the  operation  seems  as  severe  and  difficult  as  cceliotomy, 
which  would  be,  in  every  way,  preferable. 

Means  of  Destroying-  the  Vitality  of  the  Foetus. — Another 
mode  of  managing  these  cases  is  to  destroy  the  foetus,  so  as  to  check 
its  further  growth,  in  the  hope  that  it  may  remain  inert  and  passive 
within  its  sac.  Various  operations  have  been  suggested  and  practised 
for  this  purpose.  Thus  needles  have  been  introduced  into  the  tumor, 
through  which  currents  of  electricity  have  been  passed,  either  the  con- 
tinuous current,  or,  as  has  been  suggested  by  Duchenne,  a  spark  of 
frankliuic  electricity.  Hicks  and  others  have  endeavored  to  destroy 
the  foetus  by  passing  an  electro-magnetic  current  through  it  by  means 
of  a  needle.  Of  late  years  a  large  number  of  carefully  recorded  cases 
have  been  published,  chiefly  in  America,  in  which  the  faradic  current 
has  been  used,  apparently  with  perfect  success,  one  pole  being  passed 
through  the  rectum  or  vagina  to  the  side  of  the  ovum,  the  other  being 
placed  on  a  point  in  the  abdominal  wall  two  or  three  inches  above 
Pou part's  ligament ;  or  Apostoli's  vaginal  electrode,  in  which  both 
poles  are  combined,  might  be  used.  The  number  of  cases  is  so  con- 
siderable1 that  it  is  quite  futile  to  talk  of  this  plan  as  "mere  non- 
sense," or  unworthy  of  consideration.  On  the  contrary,  under  the 
conditions  already  mentioned,  when  coeliotomy  is  not  feasible,  it 
appears  to  offer  a  very  hopeful  resource.  The  current  should  be  passed 
daily  for  at  least  ten  minutes,  and  continued  for  a  week  or  two  until 
the  shrinking  of  the  tumor  gives  satisfactory  evidence  of  the  death  of 
the  foetus.  This  practice  is  perfectly  safe,  and  there  can  be  no  rational 
objection  to  its  being  tried.  Aveling  makes  the  reasonable  suggestion 
that  the  current  acts  by  producing  "  tetanic  contractions  of  the  foetal 
heart  due  to  the  repeatedly  broken  current  of  an  induction  machine."2 
Simple  puncture  of  the  cyst  has  been  successfully  practised  on  several 
occasions,  either  with  a  small  trocar  and  canula,  or  with  a  simple 
needle.  A  very  interesting  case,  in  which  the  development  of  a  two 
months'  tubal  gestation  was  arrested  in  this  way,  is  recorded  by 
Greenhalgh,3  and  another  by  Martin,  of  Berlin.4  Joulin  suggested 
that  not  only  should  the  cyst  be  punctured,  but  that  a  solution  of 
morphine  should  be  injected  into  it,  which,  by  its  toxic  influence, 
would  insure  the  destruction  of  the  foetus ;  and  this  is  probably  one 
of  the  best  means  at  our  disposal  for  destroying  the  foetus.  Friedreich 
and  others  have  reported  successful  cases,  one-fifth  of  a  grain  of  mor- 
phine being  injected  into  the  sac  every  second  day,  until  it  had 
obviously  begun  to  shrink. 

Other  means  proposed  for  effecting  the  same  object,  such  as  pressure, 
or  the  administration  of  toxic  remedies  by  the  mouth,  are  far  too  un- 
certain to  be  relied  on.  The  simplest  and  most  effectual  plan  would 

1  See  various  papers  in  the  Trans,  of  the  Amer.  Gyn.  Soc. ;  also  Lusk's  Midwifery,  1892. 
*  "  The  Diagnosis  and  Electrical  Treatment  of  Early  Extra-uterine  Gestation,"  Brit.  Gyn.  Joura., 
1888-89,  vol.  iv.  p.  24. 
»  Lancet,  18677  4  Monat.  f.  Geburt.,  1868,  Bd.  xxxii.  3.  140. 


190  PREGNANCY. 

be  to  introduce  the  needle  of  an  aspirator,  by  which  the  liquor  amnii 
would  be  drawn  off,  and  the  further  growth  of  the  foetus  effectually 
prevented.  Parry,1  indeed,  is  opposed  to  this  practice,  and  has  col- 
lected several  cases  in  which  the  puncture  of  the  cyst  was  followed  by 
fatal  results,  either  from  hemorrhage  or  septicjemia.  In  these,  how- 
ever, an  ordinary  trocar  and  canula  were  probably  employed,  which 
would  necessarily  admit  air  into  the  sac.  It  is  difficult  to  imagine 
that  a  fine  hair-like  aspirating  needle,  rendered  perfectly  aseptic  by 
carbolic  acid,  could  have  any  injurious  results;  and  it  could  do  no 
harm,  even  if  an  error  of  diagnosis  had  been  made,  and  the  suspected 
extra-uterine  fcetation  turned  out  to  be  some  other  sort  of  growth.  If 
the  aspirator  proves  that  an  extra-uterine  foetation  exists,  then,  if  the 
cyst  be  of  any  considerable  size,  and  the  pregnancy  advanced  beyond 
the  second  month,  we  might,  if  deemed  advisable,  resort  to  a  more 
radical  operation. 

Treatment  when  Rupture  has  Occurred. — When  the  chance  of 
arresting  the  growth  of  a  tubular  foetation  has  never  arisen,  and  we 
first  recognize  its  existence  after  laceration  has  occurred,  and  the  patient 
is  collapsed  from  hemorrhage,  what  course  are  we  to  pursue  ?.  Hitherto 
all  that  has  generally  been  done  is  to  attempt  to  rally  the  patient  by 
stimulants,  and,  in  the  unlikely  event  of  her  surviving  the  immediate 
effects  of  laceration,  endeavoring  to  control  the  subsequent  peiitonitis, 
in  the  hope  that  the  effused  blood  may  become  absorbed,  as  in  pelvic 
haematocele.  This  is,  indeed,  a  frail  reed  to  rest  upon,  and  when  lacera- 
tion of  a  tubal  gestation,  advanced  beyond  a  month,  has  occurred, 
death  has  been  the  almost  certain  result.  It  is  now  universally  ad- 
mitted that  in  such  cases  practically  the  only  hope  for  the  patient  lies 
in  the  immediate  performance  of  coeliotomy,  the  rapid  clearing  away 
of  the  effused  blood,  and  the  search  for,  and  ligature  of,  the  ruptured 
tube.  Mr.  Lawson  Tait's  brilliant  record  of  42  cases,  39  of  which 
recovered,  would  alone  prove  this  to  be,  beyond  any  question,  the 
proper,  and  indeed  the  only  possible,  practice,  and  happily  many  others 
are  now  able  to  record  similar  results.  In  these  cases,  in  which  rup- 
ture is  never  delayed  beyond  the  twelfth  or  thirteenth  week  of  gesta- 
tion, there  are  rarely  any  adhesions,  and  the  operation  presents  no 
particular  difficulty.  As  a  rule,  death  does  not  follow  rupture  for 
some  hours,  so  that  there  would  be  usually  time  for  the  operation,  and 
the  extreme  prostration  might  be,  perhaps,  temporarily  counteracted 
by  saline  transfusion.  Pressure  on  the  abdominal  aorta,  resorted  to 
when  the  patient  is  first  seen,  might  possibly  be  employed  with  advan- 
tage to  check  further  hemorrhage,  until  the  question  of  operation  is 
decided.  We  must  remember  that  the  alternative  is  death,  and  hence 
any  operation  which  would  afford  the  slightest  hope  of  success  would 
be  perfectly  justifiable. 

In  the  second  class  of  cases,  in  which  the  rupture  is  extra-peritoneal, 
the  necessity  for  immediate  operation  is  not  so  urgent.  Cases  of  this 
kind  are  not  so  intense  in  their  character,  and  they  rally  much  more 
completely ;  if  they  do  so,  it  will  doubtless  be  best  not  to  interfere 
until  a  later  date. 

1  Parry  on  Extra-uterine  Pregnancy,  p.  204. 


ABNORMAL    PREGNANCY. 


191 


Abdominal  Pregnancy. — In  the  second  of  the  two  classes  into 
which,  for  practical  convenience,  we  have  divided  extra-uterine  gesta- 
tion, the  ovum  is  developed  in  the  abdominal  cavity.  It  is,  as  we 
have  seen,  very  questionable  if  there  is  such  a  condition  as  primary 
abdominal  pregnancy.  Practically  we  may  consider  all  the  cases  in 
which  the  foetus  has  developed  in  the  abdominal  cavity  to  have  been 
primarily  tubal  or  interstitial.  Either  the  tube  has  burst  into  the 
peritoneum  at  a  very  early  period  of  pregnancy,  and  the  ovum  has 
maintained  its  vitality,  or,  more  commonly,  there  has  been  an  extra- 
peritoneal  rupture,  and  subsequently  the  gestation  sac  has  again  given 
way,  and  the  foetus  has  found  its  way  into  the  abdominal  cavity. 


FIG.  87. 


Uterus  and  foetus  in  a  case  of  abdominal  pregnancy. 

Formation  of  a  Cyst  around  the  Ovum. — In  the  large  majority 
of  cases  the  ovum  produces  considerable  irritation,  resulting  in  the 
exudation  of  plastic  material,  which  is  thrown  around  it,  so  as  to  form 
a  secondary  cyst  or  capsule,  in  which  maternal  vessels  are  largely 
developed,  and  which  stretches,  pari  passu,  with  the  growth  of  the 
ovum  (Fig.  87).  This  may  be  partly  composed  of  remnants  of  rup- 
tured tube,  and  of  the  layers  of  the  broad  ligament,  and  to  its  external 
surface  portions  of  intestine  and  omentum  are  frequently  adherent. 
The  placenta  may  be  variously  attached ;  sometimes  above  the  foetus 
at  the  upper  part  of  the  sac,  sometimes  below  it,  or  partially  to  some 
of  the  adjacent  abdominal  viscera.  The  density  and  strength  of  this 
cyst  are  found  to  be  very  different  in  different  cases ;  sometimes  it 
forms  a  complete  and  strong  covering  to  the  ovum,  at  others  it  is  very 
thin  and  only  partially  developed,  but  it  is  rarely  entirely  absent.  As 
there  is  ample  space  for  the  development  of  the  ovum,  and  as  the 
secondary  cyst  generally  stretches  and  grows  along  with  it,  most  cases 
of  abdominal  pregnancy  progress  without  any  very  remarkable  symp- 
toms beyond  occasional  severe  attacks  of  pain,  until  the  full  term  of 
pregnancy  has  been  reached.  Sometimes,  however,  the  cyst  lacerates, 
and  there  is  an  escape  of  blood  into  the  abdominal  cavity,  accompanied 


192 


PREGNANCY. 


by  more  or  less  prostration  and  collapse,  which  may  prove  fatal,  but 
from  which  the  patient  more  generally  rallies.  The  foetus,  now  dead, 
will  remain  in  the  abdomen,  and  will  undergo  changes  and  produce 
results  similar  to  those  which  we  shall  presently  describe  as  occurring 
in  cases  progressing  to  the  full  period. 

In  most  cases,  at  the  natural  termination  of  pregnancy  a  strange 
series  of  phenomena  occur  ;  pseudo-labor  comes  on,  there  are  more  or 
less  frequent  and  strong  uterine  contractions,  possibly  an  escape  of 
blood  from  the  vagina,  the  discharge  of  the  broken-down  uterine 
decidua,  and  even  the  establishment  of  lactation.  Sometimes  the  con- 
tractions of  the  abdominal  muscles  produced  by  this  ineffective  labor 
have  been  so  strong  as  to  cause  the  laceration  of  the  adventitious  cyst 
surrouding  the  foetus,  and  the  escape  of  blood  and  liquor  amnii  into 
the  abdominal  cavity,  with  a  rapidly  fatal  result.  More  frequently 
laceration  does  not  occur,  and  the  spurious  labor-pains  continue  at 
intervals,  until  the  foetus  dies,  possibly  from  pressure,  but  more  often 
from  effusion  of  blood  into  the  tissue  of  the  placenta,  and  consequent 
asphyxia.  Occasionally  the  fcetus  has  apparently  lived  a  considerable 
time,  in  some  cases  even  for  several  mouths,  after  the  natural  limit  of 
pregnancy  has  been  reached. 

Changes  after  the  Death  of  the  Foetus. — It  is  after  the  death  of 
the  foetus  that  the  dangers  of  abdominal  pregnancy  generally  com- 
mence, and  they  are  numerous  and  various.  The  subsequent  changes 
that  occur  are  well  worthy  of  study.  Occasionally  the  foetus  has  been 
retained  for  a  length  of  time,  even  until  the  end  of  a  long  life,  without 

producing  any  serious  discomfort,  and  in 
many  cases  of  this  kind  several  normal 
pregnancies  and  deliveries  have  subse- 
quently taken  place.  Even  when  the 
extra-uterine  gestation  appears  to  be  tol- 
erated, and  has  remained  for  long  without 
producing  any  bad  effects,  serious  symp- 
toms may  be  suddenly  developed ;  so  that 
no  woman,  under  such  circumstances,  can 
be  considered  safe.  The  condition  of 
these  retained  foetuses  varies  much.  Most 
commonly  the  liquor  amnii  is  absorbed, 
the  foetus  shrinks  and  dies,  all  its  soft 
structures  are  changed  into  adipocere,  and 
the  bones  only  remain  unaltered.  Some- 
times this  change  occurs  with  great  rapid- 
ity. I  have  elsewhere1  recorded  a  case  of 
extra-uterine  foetation  in  which  at  the  full 
term  of  pregnancy  the  foetus  was  alive, 
and  the  woman  died  in  less  than  a  year 
afterward.  On  post-mortem  examination 
the  foetus  was  found  entirely  transformed  into  a  greasy  mass  of  adi- 
pocere, studded  with  foetal  bones,  in  which  not  a  "trace  of  any  of  the 


FIG.  88. 


Lithopaedion.  (From  a  preparation 
in  the  Museum  of  the  College  of  Sur- 
geons.) 


Obst.  Trans.,  1865.  vol.  vii.  p.  1. 


ABNORMAL    PREGNANCY.  193 

soft  parts  could  be  detected.  Ou  the  other  hand,  the  foetus  may  remain 
unchanged ;  in  the  Museum  of  the  College  of  Surgeons  there  is  one 
which  was  retained  in  the  abdomen  for  fifty-two  years,  and  which  was 
found  to  be  as  fresh  and  unaltered  as  a  newborn  child.  In  other  cases 
the  sac  and  its  contents  atrophy  and  shrink,  and  calcareous  matter  is 
deposited  in  them,  so  that  the  whole  becomes  converted  into  a  solid 
mass  known  as  lithopcedion  (Fig.  88).  The  cases,  however,  in  which 
the  retention  of  the  foetus  gives  rise  to  no  mischief  are  quite  excep- 
tional. Generally  the  foetus  putrefies,  and  this  may  either  immediately 
cause  fatal  peritonitis  or  septicaemia,  or,  as  more  commonly  happens, 
secondary  inflammation  and  suppuration  of  the  sac.  Under  the  influ- 
ence of  the  latter  the  sac  opens  externally,  either  directly  at  some  point 
of  the  abdominal  walls,  or  indirectly  through  the  vagina,  the  bowels,  or 
even  the  bladder.  Through  the  aperture  or  apertures  thus  formed  (for 
there  are  often  several  fistulous  openings),  pus,  and  the  bones  and  other 
parts  of  the  broken-down  foetus  are  discharged ;  and  this  may  go  on 
for  months,  and  even  years,  until  at  last,  if  the  patient's  strength  does 
not  give  way,  the  Avhole  contents  of  the  cyst  are  expelled,  and  recovery 
takes  place.  From  various  statistical  observations  it  appears  that  the 
chances  of  recovery  are  best  when  the  cyst  opens  through  the  abdom- 
inal walls,  next  through  the  vagina  or  bladder,  and  that  the  foetus  is 
discharged  with  most  difficulty  and  danger  when  the  aperture  is  formed 
into  the  bowel.  At  the  best,  however,  the  process  is  long,  tedious,  and 
full  of  danger;  and  the  patient  too  often  sinks,  during  the  attempt  at 
expulsion,  through  the  irritation  and  exhaustion  produced  by  the  abun- 
dant and  long-continued  discharge. 

Diagnosis. — The  diagnosis  of  abdominal  gestation  is  by  no  means 
so  easy  as  might  be  thought,  and  the  most  experienced  practitioners 
have  been  mistaken  with  regard  to  it. 

The  most  characteristic  symptom,  although  this  is  not  so  common  as 
in  tubal  gestation,  is  metrorrhagia  combined  with  the  general  signs  of 
pregnancy.  Very  severe  and  frequently  repeated  attacks  of  abdominal 
pain  are  rarely  absent,  and  should  at  once  cause  suspicion,  especially  if 
associated  with  hemorrhage,  and  the  discharge  of  a  decidual  membrane 
from  the  uterus.  They  are  supposed  by  some  to  depend  on  inter- 
current  attacks  of  peritonitis,  by  which  the  foetal  cyst  is  formed.  Parry 
doubts  this  explanation,  and  attributes  them  partly  to  the  distention 
of  the  cyst  by  the  growing  foetus,  and  partly  to  pressure  on  the  sur- 
rounding structures.  On  palpation  the  form  of  the  abdomen  will  be 
observed  to  differ  from  that  of  normal  pregnancy,  being  generally 
more  developed  in  the  transverse  direction,  and  the  rounded  outline  of 
the  gravid  uterus  cannot  be  detected.  When  development  has  advanced 
nearly  to  term,  the  extreme  distinctness  with  which  the  foetal  limbs 
can  be  felt  will  arouse  suspicion.  Per  vaginam  the  os  and  cervix  will 
be  felt  softened,  as  in  ordinary  pregnancy,  but  often  displaced  by  the 
pressure  of  the  cyst,  and  sometimes  fixed  by  peri-metritic  adhesions; 
either  of  these  signs  is  of  great  diagnostic  value. 

By  bimanual  examination  it  may  be  possible  to  make  out  that  the 
uterus  is  not  greatly  enlarged,  and  that  it  is  distinctly  separate  from 
the  bulk  of  the  tumor :  these  facts,  if  recognized,  would  of  themselves 

13 


194  PREGNANCY. 

disprove  the  existence  of  uterine  gestation.  The  diagnosis,  if  the 
foetal  limbs  or  heart-sounds  could  be  detected,  would  be  cleared  up  in 
any  case  by  the  uterine  sound,  which  would  show  that  the  uterus  was 
empty  and  only  slightly  elongated.  But  we  must  be  careful  not  to 
resort  to  this  test  unless  the  existence  of  uierint  gestation  is  positively 
disproved  by  other  means.  As,  however,  it  places  the  diagnosis  beyond 
a  doubt,  it  should  always  be  employed  whenever  operative  procedure 
is  in  contemplation.  Quite  recently  I  have  seen  a  remarkable  case 
which  illustrates  the  importance  of  this  rule.  The  case  had  been 
diagnosed  as  abdominal  pregnancy  by  no  fewer  than  six  experienced 
practitioners,  and  was  actually  on  the  operating-table  for  the  per- 
formance of  cceliotomy.  As  a  precaution,  having  some  doubts  of  the 
diagnosis,  I  suggested  the  passage  of  the  sound,  which  entered  into  a 
gravid  uterus,  the  case  proving  to  be  one  of  small  ovarian  tumor 
jammed  down  into  Douglas'  space,  and  displacing  the  cervix  forward. 
Had  it  not  been  for  this  precaution  its  true  nature  would  certainly  not 
have  been  detected. 

Treatment. — The  treatment  of  abdominal  gestation  will  always  be 
a  subject  of  anxious  consideration,  and  there  is  much  difference  of 
opinion  as  to  the  proper  course  to  pursue.  It  is  becoming  more 
generally  recognized  as  good  practice,  that  when  the  existence  of  an 
abdominal  pregnancy  is  thoroughly  established,  no  matter  what  the 
period  of  pregnancy,  the  sooner  it  is  operated  on  the  better.  Punc- 
turing the  cyst,  with  the  view  of  destroying  the  fcetus  and  arresting  its 
further  growth,  has  been  practised,  but  there  are  good  grounds  for 
rejecting  it,  for  there  is  not  the  same  imminent  risk  of  death  from  rup- 
ture of  the  cyst  as  in  tubal  foetation  ;  and,  even  if  the  destruction  of  the 
foetus  could  be  brought  about,  there  would  still  be  formidable  dangers 
from  subsequent  attempts  at  elimination,  or  from  internal  hemorrhage. 

If  we  have  to  deal  with  a  case  which  has  advanced  nearly  to  the  full 
period,  the  child  being  still  alive,  as  proved  by  auscultation,  we  have 
to  consider  Avhether  it  may  not  be  advisable  to  perform  cceliotomy 
before  the  foetus  perishes,  and  so  at  least  save  the  life  of  the  child. 
There  are  few  questions  of  greater  importance  and  more  difficult  to 
settle.  The  tendency  of  medical  opinion  is  decidedly  in  favor  of 
immediate  operation,  which  is  recommended  by  Velpeau,  Kiwisch, 
Koeberle,  Schroeder,  Tait,  and  many  other  writers,  whose  opinion 
necessarily  carries  great  weight.  The  arguments  used  in  favor  of  im- 
mediate operation  are  that  while  it  affords  a  probability  of  saving  the 
child,  the  risks  to  the  mother,  great  though  they  undoubtedly  are,  are 
not  greater  than  those  which  may  be  anticipated  by  delay.  If  we  put 
off  interference  the  cyst  may  rupture  during  the  ineffectual  efforts  at 
labor,  and  death  at  once  ensue ;  .or,  if  this  does  not  take  place,  other 
risks,  which  can  never  be  foreseen,  are  always  in  store  for  the  patient. 
She  may  sink  from  peritonitis,  or  from  exhaustion,  consequent  on  the 
efforts  at  elimination,  which  in  the  majority  of  cases  are  sooner  or  later 
set  up,  so  that,  as  Barnes  properly  says,  "  the  patient's  life  may  be  said 
to  be  at  the  mercy  of  accidents  of  which  we  have  no  sufficient  warn- 
ing." On  the  other  hand,  if  we  delay,  while  we  sacrifice  all  hope  of 
saving  the  child,  we  at  least  give  the  mother  the  chance  of  the  foetation 


ABNORMAL    PREGNANCY.  195 

remaining  quiescent  for  a  length  of  time,  as  certainly  not  unfrequently 
occurs.  .  Thus,  Campbell  collected  62  cases  of  ultimate  recovery  after 
abdominal  gestation,  in  21  of  which  the  foetus  was  retained  without 
injury  for  a  number  of  years.  Then  there  is  the  question  of  secondary 
coeliotomy,  which  consists  in  operating  after  the  death  of  the  foetus 
when  urgent  symptoms  have  arisen,  a  course  which  is  advocated  by 
Mr.  Hutchiuson.  In  favor  of  this  procedure  it  is  urged  that  by  delay 
the  inflammation  taking  place  about  the  cyst  will  have  greatly  increased 
the  chance  of  adhesions  having  formed  between  it  and  the  abdominal 
parietes,  so  as  to  shut  off  its  contents  from  the  cavity  of  the  peri- 
toneum. The  more  effectually  this  has  been  accomplished,  the  greater 
are  the  chances  of  recovery.  When  the  foetus  has  been  dead  for  some 
time,  the  vascularity  of  the  cyst  will  also  be  lessened,  the  placental 
circulation  will  have  ceased,  and  that  viscus  will  have  become  solid 
and  tough,  so  that  the  danger  of  hemorrhage  will  be  much  diminished. 

It  will  be  seen,  therefore,  that  there  are  arguments  in  favor  of  each 
of  these  views.  The  results  of  the  primary  operation  are  far  less  favor- 
able than  we  should  have,  CL  priori,  supposed.  Since  the  first  edition  of 
this  work  appeared  the  subject  has  been  carefully  studied  by  Dr.  Parry 
in  his  exhaustive  treatise  on  Extra-uterine  Fcetation.  He  has  there  shown 
that  when  the  case  is  left  until  Nature  has  shown  the  channel  through 
which  elimination  is  to  be  effected,  the  mortality  is  17.35  per  cent, 
less  .than  in  the  cases  in  which  the  primary  operation  was  per- 
formed. His  conclusion  is  that  "  the  primary  operation  cannot  be  too 
forcibly  condemned.  It  is  not  too  much  to  say  that  this  operation 
adds  only  another  danger  to  a  life  already  trembling  in  the  balance, 
which  the  delusive  hope  of  saving  the  uncertain  life  of  a  child  does 
not  warrant  us  in  assuming."  It  is  only  just  to  remember,  however, 
that  in  these  days  of  advanced  abdominal  surgery  a  better  result  may 
be  anticipated  than  when  cceliotomy  was  performed  in  the  haphazard 
way  which  was  usual  before  we  had  gained  experience  from  ovariotomy. 
No  doubt,  minute  care  in  the  performance  of  the  operation,  a  due  atten- 
tion to  its  details,  studiously  avoiding,  as  much  as  possible,  the  passage 
of  blood  and  the  contents  of  the  cyst  into  the  peritoneal  cavity,  and  a 
free  use  of  antiseptics,  will  materially  lessen  its  peril. 

Mode  of  Performing  the  Operation. — The  operation  should  be 
performed  with  all  the  precautions  with  which  we  surround  ovari- 
otomy. The  incision,  best  made  in  the  linea  alba,  should  not  be 
greater  than  is  necessary  to  extract  the  foetus,  and  may  be  lengthened 
as  occasion  requires.  If  there  are  no  adhesions,  the  walls  of  the  cyst 
should  be  stitched  to  the  margin  of  the  incision,  so  as  to  shut  it  off  as 
completely  as  possible  from  the  peritoneal  cavity.  This  has  been 
specially  insisted  on  by  Braxton  Hicks,  and  should  never  be  omitted. 
The  special  risk  is  not  so  much  the  wounding  of  the  peritoneum  as 
the  subsequent  entrance  of  septic  matter  from  the  cyst  into  its  cavity. 
It  has  been  laid  down  as  a  rule  that  after  incising  the  sac  no  attempt 
should  be  made  to  remove  the  placenta.  Its  attachments  are  generally 
so  deep-seated  and  diffused  that  any  endeavor  to  separate  it  is  likely 
to  be  attended  with  profuse  and  uncontrollable  hemorrhage,  or  with 
serious  injury  to  the  structures  to  which  it  is  attached.  Many  of  the 


196  PREGNANCY. 

failures  after  operating  can  be  traced  to  a  neglect  of  this  rule.  The 
best  subsequent  course  to  pursue,  after  removing  the  foetus  and  arrest- 
ing all  hemorrhage,  either  by  ligature  or  the  actual  cautery,  is  to 
sponge  out  the  cyst  as  gently  as  possible,  sprinkle  the  cavity  with 
iodoform,  or  with  equal  parts  of  tannin  and  salicylic  acid,  as  recom- 
mended by  Freund,1  and  then  to  bring  the  upper  part  of  the  wound 
into  apposition  with  sutures,  leaving  the  lower  open,  so  as  to  insure 
an  outlet  for  the  escape  of  the  placenta  as  it  slips  down.  The  subse- 
quent treatment  must  be  specially  directed  to  favor  the  escape  of  the 
discharge,  and  to  prevent  the  risk  of  septicaemia.  These  objects  may 
be  much  aided  by  injections  of  antiseptic  fluids,  such  as  solution 
of  carbolic  acid,  or  creoliu  and  water ;  and  it  would  probably  be 
advisable  to  place  a  drainage-tube  in  the  lower  angle  of  the  wound. 

As  long  as  the  placenta  is  retained  the  danger  is  necessarily  great, 
and  it  may  be  many  days,  or  even  weeks,  before  it  is  discharged. 
When  once  this  is  effected  the  sac  may  be  expected  to  contract,  and 
eventually  to  close  entirely. 

Excision  of  the  Cyst. — The  more  advanced  school  of  operators 
have  of  late  years  advised  the  complete  excision  of  the  sac  and  placenta, 
especially  in  the  primary  operation,  a  procedure  which  would  probably 
be  more  feasible  when  gestation  has  not  advanced  to  term.  This  has 
been  the  course  adopted  with  considerable  success  by  Martin,  of 
Berlin,  Breisky,  of  Vienna,  and  others.  In  this  operation,  after  re- 
moving the  foetus,  the  gestation  sac  and  placenta  has  been  ligatured, 
bit  by  bit,  and  removed,  without  any  attempt  at  tearing  or  separating 
the  placenta,  and  thus  the  uncontrollable  hemorrhage,  which  has  been 
so  serious  a  danger  when  the  placenta  is  interfered  with,  is  avoided. 
It  is  needless  to  point  out  that  such  a  procedure  is  only  likely  to 
succeed  in  the  hands  of  operators  thoroughly  self-reliant  and  conver- 
sant with  the  details  of  abdominal  surgery.  Under  such  conditions, 
since  it  materially  lessens  the  risk  of  septic  infection,  which  must 
always  be  excessive  when  the  cyst  and  placenta  remain  in  the  abdomen, 
it  is  clearly  the  most  hopeful  resource,  and  it  is  by  some  such  operation 
as  this  that,  in  future,  cases  of  primary  operation  will  be  dealt  with. 

Treatment. — When  the  foetus  is  dead,  or  when  we  have  determined 
not  to  attempt  primary  cceliotomy,  it  is  advisable  to  wait,  very  care- 
fully watching  the  patient,  until  either  the  gravity  of  her  general 
symptoms,  or  some  positive  indication  of  the  channel  through  which 
Nature  is  about  to  attempt  to  eliminate  the  foetus,  shows  us  that 
the  time  for  action  has  arrived.  If  there  be  distinct  bulging  of  the 
cyst  in  the  vagina,  or  in  the  retro-uterine  cul-de-sac,  especially  if  an 
opening  has  formed  there,  we  may  properly  content  ourselves  with 
aiding  the  passage  of  the  foetus  through  the  channel  thus  indicated, 
and  removing  the  parts  that  present  piecemeal  as  they  come  within 
reach,  cautiously  enlarging  the  aperture  if  necessary.  If  the  sac  have 
opened  into  the  intestines,  the  expulsion  of  the  foetus  through  this 
channel  is  so  tedious  and  difficult,  the  exhaustion  attending  it  so 
likely  to  prove  fatal,  and  the  danger  from  decomposition  of  the  foetus 

i  Edin.  Med.  Journ.,  voL  1883-84,  p.  521. 


ABNORMAL    PREGNANCY.  197 

through  passage  of  intestinal-  gas  so  great,  that  it  would  probably  be 
best  to  attempt  to  remove  it  by  coeliotomy,  especially  if  it  is  only 
recently  dead,  and  the  greater  portion  is  still  retained. 

Mode  of  Performing  Secondary  Cceliotomy. — If  an  opening 
forms  in  the  abdominal  parietes,  or  if  the  symptoms  determine  us  to 
resort  to  secondary  coeliotomy  before  this  occurs,  the  operation  must 
be  performed  in  the  same  way,  and  with  the  same  precautions  as 
primary  coeliotomy.  This  operation  is  not  only  more  simple,  but 
much  more  successful  than  the  primary.  Bland  Button1  gives  a  list  of 
seven  cases  operated  on  after  the  death  of  the  foetus  at  or  near  term,  in 
all  of  which  the  mothers  recovered.  This  is  doubtless  due  to  changes 
in  the  placental  circulation,  which  renders  its  connections  much  less 
vascular  and  facilitate  its  separation,  and  these  are  believed  to  be 
completed  about  ten  weeks  after  foetal  death,  so  that  the  operation 
should  be  postponed,  if  possible,  until  that  time  has  elapsed  after  the 
supposed  death  of  the  child.  The  placenta  should  be  left  to  exfoliate 
spontaneously,  and  the  cavity  of  the  sac  treated  as  after  the  primary 
operation.  Here,  as  before,  the  safety  of  the  operation  must  greatly 
depend  on  the  amount  and  firmness  of  the  adhesions  ;  for  if  the  cyst 
be  not  completely  shut  off  from  the  peritoneal  cavity,  the  risks  of  the 
operation  will  be  little  less  than  those  of  primary  cceliotomy.  It 
would  obviously  materially  influence  our  decision  and  prognosis  if  we 
could  determine  this  point  before  operating.  Unfortunately,  it  is 
impossible,  as  the  experience  of  ovariotomists  proves,  to  ascertain  the 
existence  of  adhesions  with  any  certainty.  If,  however,  we  find  that 
the  abdominal  parietes  do  not  move  freely  over  the  cyst,  and  if  the 
umbilicus  be  depressed  and  immovable,  the  presumption  is  that  con- 
siderable adhesions  exist.  If  they  are  found  not  to  be  present,  the 
cyst  walls  should  be  stitched  to  the  margin  of  the  incision,  in  the 
manner  already  indicated,  before  the  contents  are  removed. 

If  the  foetus  has  been  long  dead,  and  its  tissues  greatly  altered,  its 
removal  may  be  a  matter  of  difficulty.  In  the  case  under  my  own 
care,  already  alluded  to,  the  fetal  structures  formed  a  sticky  mass  of 
such  a  nature  that  I  believe  it  would  have  been  impossible  to  empty 
the  cyst  had  an  operation  been  attempted.  This  would  be,  to  some 
extent,  a  further  argument  in  favor  of  the  primary  operation. 

Opening"  of  Cyst  by  Caustics. — The  importance  of  adhesions  lias 
led  some  practitioners  to  recommend  the  opening  of  the  cyst  by  potassa 
fusa  or  some  other  caustic,  in  the  hope  that  it  would  set  up  adhesive 
inflammation  around  the  aperture  thus  formed.  Several  successful 
operations  by  this  method  are  recorded,  and  it  would  be  worth  trying, 
should  the  extreme  mobility  of  the  cyst  lead  us  to  suspect  that  no 
adhesions  existed.  If  we  have  to  deal  with  a  case  in  which  fistulous 
openings  leading  to  the  cyst  have  already  formed,  it  may,  perhaps,  be 
advisable  to  dilate  the  apertures  already  existing,  rather  than  make  a 
fresh  incision;  but,  in  determining  this  point,  the  surgeon  will 
naturally  be  guided  by  the  nature  of  the  case,  and  the  character  and 
direction  of  the  fistulous  openings. 

»  Op.  clt.,  p.  425. 


198  PREGNANCY. 

General  Treatment. — It  is  almost  .needless  to  say  anthing  of 
general  treatment  in  these  trying  cases ;  but  the  administration  of 
opiates  to  allay  the  sufferings  of  the  patient,  and  the  endeavor  to  sup- 
port the  severely  taxed  vital  energies  by  appropriate  food  and  medica- 
tion, will  form  a  most  important  part  of  the  management.  Freund 
specially  insists  on  the  importance  of  careful  regulation  of  the  bowels, 
and  on  making  milk  the  staple  article  of  diet,  as  important  points  in 
the  management  of  cases  prior  to  operation. 

Gestation  in  a  Bi-lobed  Uterus. — A  few  words  may  be  said  as  to 
gestation  in  the  rudimentary  horn  of  a  bi-lobed  uterus,  to  which  con- 
siderable attention  lias  of  late  years  been  directed  by  the  writings  of 
Kussmaul  and  others.  It  appears  certain  that  many  cases  of  supposed 
tubal  gestation  are  really  to  be  referred  to  this  category.  Although 
such  cases  are  of  interest  pathologically,  they  scarcely  require  much 
discussion  from  a  practical  point  of  view,  inasmuch  as  their  history  is 
pretty  nearly  identical  with  that  of  tubal  pregnancy*  The  rudimentary 
horn  is  distended  by  the  enlarging  ovum,  and  after  a  time,  when  further 
distention  is  impossible,  laceration  takes  place.  As  a  matter  of  fact,  all 
the  thirteen  cases  collected  by  Kussmaul  terminated  in  this  way ;  and 
even  on  post-mortem  examination  it  is  often  extremely  difficult  to  dis- 
tinguish them  from  tubal  pregnancies.  The  best  way  of  doing  so  is 
probably  by  observing  the  relations  of  the  round  ligament  to  the 
tumor ;  for,  if  the  gestation  be  tubal,  it  will  be  found  attached  to  the 
uterus  on  the  inner  or  uterine  side  of  the  cyst;  whereas,  if  the  preg- 
nancy be  in  a  rudimentary  horn  of  the  uterus,  it  will  be  pushed  out- 
ward, and  be  external  to  the  sac.  In  the  latter  case,  moreover,  the 
sac  will  be  probably  found  to  contain  a  true  decidua,  which  is  not  the 
case  in  tubal  pregnancy.  The  only  point  in  which  they  differ  is  that 
in  cornual  pregnancy,  rupture  may  be  delayed  to  a  somewhat  later 
period  than  in  tubal,  on  account  of  the  greater  distensibility  of  the 
supplementary  horn. 

Missed  Labor. — The  term  "missed  labor"  is  applied  to  an  exceed- 
ingly rare  class  of  cases  in  which,  at  the  full  period  of  pregnancy, 
labor  has  either  not  come  on  at  all,  or,  having  commenced,  the  pains 
have  subsequently  passed  off,  and  the  foetus  is  retained  in  ute.ro  for  a 
.very  considerable  length  of  time.  Under  such  circumstances  it  has 
usually  happened  that  the  membranes  have  ruptured  at  or  about  the 
proper  term,  and  the  access  of  air  to  the  foetus  in  utero  has  been  followed 
by  decomposition.  A  putrid  and  offensive  discharge  has  then  com- 
menced, and  eventually  portions  of  the  disintegrating  foetus  have  been 
expelled  per  vaginam.  This  discharge  may  go  on  until  the  entire  foetus 
is  gradually  thrown  off;  or,  more  frequently  the  patient  dies  from  sep- 
ticaemia, or  other  secondary  result  of  the  presence  of  the  decomposing 
mass  in  utero.  Thus  McClintock  relates  one  case,1  in  which  symptoms 
of  labor  came  on  in  a  woman,  forty-five  years  of  age,  at  the  expected 
period  of  delivery,  but  passed  off  without  the  expulsion  of  the  foetus. 
For  a  period  of  sixty-seven  weeks  a  highly  offensive  discharge  came 
away,  with  some  few  bones,  and  she  eventually  died  with  symptoms 

1  Dublin  Quarterly  Journal,  Feb.  and  May,  1864. 


ABNORMAL    PREGNANCY. 


199 


of  pyaemia.     He  also  cites  another  case  in  which  the  patient  died  in 
the  same  way,  after  the  foetus  had  been  retained  for  eleven  years. 

Sometimes  when  the  fcetus  has  been  retained  for  a  length  of  time,  a 
further  source  of  danger  has  been  added  by  ulceration  or  destruction 
of  the  uterine  walls,  probably  in  consequence  of  an  ineffectual  attempt 
at  its  elimination.  This  occurred  in  Dr.  Oldham's  case  (Fig.  89),  in 
which  the  contained  mass  is  said  to  have  nearly  worn  through  the 
anterior  wall  of  the  uterus ;  and  also  in  one  reported  by  Sir  James 
Simpson,1  in  which  a  patient  died  three  months  after  term,  the  fcetus 
having  undergone  fatty  metamorphosis,  an  opening  the  size  of  half-a- 
crown  having  formed  between  the  transverse  colon  and  the  uterine 
cavity.  It  is  also  stated  that  "the  uterine  walls  were  as  thin  as 
parchment." 

FIG.  89. 


Contents  of  the  cyst  in  Dr.  Oldham's  case  of  missed  labor. 

In  some  few  cases,  however,  probably  when  the  entrance  of  air  has 
been  prevented,  the  foetus  has  been  retained  for  a  length  of  time  with- 
out decomposing,  and  without  giving  rise  to  any  troublesome  symp- 
toms. Such  a  case  is  reported  by  Dr.  Cheston/  in  which  the  foetus 
remained  in  utero  for  fifty-two  years. 

The  causes  of  this  strange  occurrence  are  altogether  unknown. 
Generally  the  fcetus  seems  to  have  died  some  time  before  the  proper 
term  for  labor,  and  this  may  have  influenced  the  character  of  the 
pains.  It  is  probably  also  most  apt  to  occur  in  women  of  feeble  and 
inert  habit  of  body,  possibly  where  there  was  some  obstacle  to  the 


Edin.  Med.  Journal,  1865. 


Med.-Chir.  Trans.,  1814. 


200  PREGNANCY. 

dilatation  of  the  cervix,  which  the  pains  were  unable  to  overcome. 
Barnes  suggests1  that  some  presumed  examples  of  missed  labor  "  were 
really  cases  of  interstitial  gestation,  or  gestation  in  one  horn  of  a  two- 
horned  uterus;"  and  Macdonald2  recently  recorded  a  very  interesting 
case  in  which  he  performed  coeliotomy  for  what  he  believed  to  be  a 
uterine  fibroid,  but  which  turned  out  to  be  one  horn  of  a  bifurcated 
uterus  containing  a  foetus  which  had  been  retained  for  more  than  a 
year.  He  believes  that  most,  if  not  all,  cases  of  "missed  labor"  are 
of  this  kind,  delivery  at  term  proving  impossible  because  of  the  narrow 
connection  between  the  impregnated  horn  and  the  cervix. 

Mailer,  of  Nancy,  has  attempted  to  prove,  by  a  critical  examination 
of  published  cases,3  that  most  examples  of  so-called  "missed  labor" 
wrere  in  reality  cases  of  extra-uterine  fostation,  in  which  an  ineffectual 
attempt  at  parturition  took  place,  the  foetus  being  subsequently  re- 
tained. 

From  what  has  been  said,  it  will  be  seen  that  the  dangers  arising 
from  this  state  are  very  considerable,  and  when  once  the  full  term  has 
passed  beyond  doubt,  especially  if  the  presence  of  an  offensive  discharge 
shows  that  decomposition  of  the  foetus  has  commenced,  it  would  be 
proper  practice  to  empty  the  uterus  as  soon  as  possible.  The  necessary 
precaution,  however,  is  not  to  decide  too  quickly  that  the  term  has 
really  passed ;  and,  therefore,  we  must  either  allow  sufficient  time  to 
elapse  to  make  it  quite  certain  that  the  case  really  falls  under  this 
category,  or  have  unequivocal  signs  of  the  death  of  the  foetus,  and 
injury  to  the  mother's  health. 

Treatment. — If  we  had  to  deal  with  the  case  before  any  extensive 
decomposition  of  the  foetus  had  occurred,  we  probably  should  find  little 
difficulty  in  its  management,  for  the  proper  course  then  would  be  to 
dilate  the  cervix  with  fluid  dilators,  and  remove  the  foetus  by  turning; 
or,  before  doing  so,  we  might  endeavor  to  excite  uterine  action  by 
pressure  and  ergot.  If  the  case  did  not  come  under  observation  until 
disintegration  of  the  foetus  had  begun,  it  would  be  more  difficult  to 
deal  Avith.  If  the  foetus  had  become  so  much  broken  up  that  it  was 
being  discharged  in  pieces,  Dr.  McCliutock  says  that  "  in  regard  to 
treatment,  our  measures  should  consist  mainly  of  palliatives,  viz.,  rest 
and  hip-baths,  to  subdue  uterine  irritation  ;  vaginal  injections,  to  secure 
cleanliness  and  prevent  excoriation  ;  occasional  digital  examination  so 
as  to  detect  any  fragments  of  bone  that  might  be  presenting  at  the  os, 
and  to  assist  in  removing  them.  These  are  plain  rational  measures, 
and  beyond  them  we  shall  scarcely,  perhaps,  be  justified  in  venturing. 
Nevertheless,  under  certain  circumstances,  I  would  not  hesitate  to  dilate 
the  cervical  canal  so  as  to  permit  of  examining  the  interior  of  the  womb, 
and  of  extracting  any  fragments  of  bone  that  may  be  easily  accessible  ; 
but  unless  they  could  thus  be  easily  reached  and  removed,  the  safer 
course  would  be  to  defer,  for  the  present,  interfering  with  them."  * 

It  may  be  doubted,  I  think,  whether,  considering  the  serious  results 
which  are  known  to  have  followed  so  many  cases,  it  would  not,  on  the 

1  Diseases  of  Women,  p.  445. 

2  Edin.  Med.  Journ.,  vol.  1884-85,  p.  873. 

3  De  la  Grossesse  uterine  prolongee  indefiniment,  Paris,  1878. 
*  Dublin.  Quart.  Jouru.,  vol.  sxxvii.  p.  314. 


ABNORMAL    PREGNANCY.  201 

whole,  be  safer  to  make  at  least  one  decided  effort,  under  chloroform, 
to  remove  as  much  as  possible  of  the  putrefying  uterine  contents,  after 
the  os  has  been  fully  dilated.  Such  a  procedure  would  be  less  irri- 
tating than  frequently  repeated  endeavors  to  pick  away  detached  por- 
tions of  the  foetus,  as  they  present  at  the  os  uteri.  When  once  the 
os  is  dilated,  antiseptic  intra-uterine  injections  might  be  safely  and 
advantageously  used.  Unquestionably,  it  would  be  better  practice  to 
interfere  and  empty  the  uterus  as  soon  as  we  are  quite  satisfied  of  the 
nature  of  the  case,  rather  than  to  delay  until  the  foetus  has  been  dis- 
integrated. Macdonald  thinks  that  abdominal  section  would  be  the 
best  course  to  pursue,  either  removing  the  sac  entire  or  resorting  to 
Porro's  operation.  This  advice  is  based  on  the  assumption  that 
"missed  labor"  is  essentially  the  retention  of  a  foetus  in  one  horn 
of  a  bi-lobed  uterus,  a  theory  which  certainly  cannot  yet  be  taken  as 
proved. 

[Causes  of  "Missed  Labor." — From  several  cases  that  have  been 
reported  in  the  United  States  we  find  that  the  failure  of  the  uterus  to 
expel  its  contents  may  be  due  to  a  variety  of  causes.  If  we  are  certain 
that  the  foetus  is  actually  in  utero,  that  there  is  no  pelvic  or  vaginal 
obstruction,  and  that  the  uterus  is  itself  of  normal  form,  then  we  must 
look  for  the  cause  of  difficulty  in  the  organ  itself.  By  an  examination 
of  our  reports  of  Ca3sarean  operations  we  find  that  there  have  been 
several  cases  in  which  the  power  of  the  uterine  contractions  was  insuffi- 
cient to  overcome  the  resistance  to  expansion  in  the  cervix.  This  may 
be  due  either  to  a  want  of  contractile  force  in  the  muscular  coat,  to  a 
change  in  the  tissues  of  the  cervix  as  the  result  of  inflammation,  or  to 
both  conditions  combined.  Where  the  muscular  power  of  the  uterus 
is  in  its  integrity,  the  resistance  in  the  cervix  may  be  such  that  the  os 
may  remain  unchanged  after  it  is  slightly  opened,  and  the  patient  con- 
tinue in  labor  until  the  contractile  power  of  the  uterus  is  exhausted, 
when  all  muscular  contraction  will  cease.  Efforts  at  expulsion  may 
recur  at  intervals  covering  a  period  of  many  months,  when  they  will 
cease  finally.  In  two  Caesarean  cases  in  the  United  States,  the  subjects 
being  black,  there  was  found  a  calcareous  incrustation  over  and  around 
the  internal  os  uteri.  The  first  operation  was  performed  in  Virginia 
in  1828  upon  a  multipara  of  twenty-five.1  She  was  taken  in  labor  at 
term,  and  had  pains  for  two  or  three  days  together,  at  intervals,  for 
about  four  weeks,  after  which  pains  returned  occasionally  during  fifteen 
months.  The  cervix  admitted  the  index  finger,  and  in  time  the  foetus 
became  putrid.  When  operated  upon  she  had  carried  the  foetus  two 
years.  There  was  very  little  hemorrhage  in  the  operation,  although 
the  uterus  failed  to  contract,  and  for  this  reason  was  sutured.  The 
woman  died  in  the  second  week,  of  peritonitis,  following  an  attack  of 
indigestion,  produced  by  a  meal  of  animal  food  and  cider.  The  second 
case,  also  a  multipara,  was  operated  upon  in  Georgia  in  1877,  after  a 
labor  of  four  days,  by  Dr.  Theodore  Starbuck,  who  describes  the  de- 
posit as  "  ossific."  The  child  was  dead,  and  the  woman  died  of  internal 
hemorrhage  very  suddenly  on  the  third  day.2 

I1  Am.  Journ  Med.  Sci.,  vol.  xviii.  p.  257.]  [a  Communicated  by  the  operator,  1880.] 


202  PREGNANCY. 

In  a  third  case,  also  black,  the  cause  of  retention  appears  to  have 
been  a  prevention  of  the  descent  of  the  foetus,  from  its  arm  and  leg 
being  secured  within  the  uterus.  The  woman  was  thirty-three  years 
.old  and  the  mother  of  one  child,  and  was  operated  upon  by  Dr.  J.  C. 
Egau,  of  Shreveport,  Louisiana,  August  25,  I860.1  On  May  4,  1857, 
while  at  work  in  the  field,  she  felt  a  sudden  and  violent  pain  in  the 
left  side ;  fainted,  remained  insensible  so  long  as  to  be  thought  dead, 
but  finally  revived,  and  was  pronounced  four  months  pregnant.  Labor 
began  in  November ;  the  os  dilated,  head  presented,  but  did  not  de- 
scend ;  pains  continued  at  intervals  for  a  month.  In  the  fall  of  1858 
an  abscess  opened,  leaving  a  fistula  one  and  a  quarter  inches  below  the 
umbilicus.  When  operated  upon  nearly  two  years  later,  she  was 
greatly  emaciated  and  affected  with  hectic  fever.  The  uterus  being 
adherent,  the  peritoneal  cavity  was  not  opened.  When  the  foetus  was 
extracted,  its  left  foot  and  hand  were  wanting,  and,  search  being  made, 
were  found  in  a  pouch  on  the  left  side  of  the  uterus,  enclosed  by  bauds 
which  were  cut  for  their  liberation.  The  uterus  was  examined  biman- 
ually  to  make  sure  that  the  cervix  was  sufficiently  open  for  drainage. 
The  decomposed  foetus  had  been  carried  thirty-three  months  after 
maturity.  Dr.  Egan  believes  that  a  partial  rupture  of  the  uterus 
took  place  at  the  time  of  her  attack  in  the  field,  and  that  the  arm  and 
leg  were  caught  in  its  partial  cicatrization.  The  woman  made  a  good 
recovery. 

Much  light  is  thrown  upon  a  possible  way  of  accounting  for  some 
of  the  mysterious  cases  of  missed  labor,  wrhich  have  been  claimed  to  be 
extra-uterine  in  order  to  account  for  them,  by  a  case  recently  operated 
upon  in  Portland,  Maine,  by  Dr.  Stanley  P.  AVarren,  and  kindly 
reported  to  me  by  letter.  The  woman  was  a  native,  of  Scotch-Irish 
descent,  aged  thirty-two,  and  mother  of  a  child  of  thirteen.  She  last 
menstruated  in  January,  1884.  Supposed  accidental  abortion  in  May, 
as  there  was  hemorrhage;  the  physician  said  he  had  removed  the 
placenta,  and  there  was  a  thick  "molasses-like"  discharge  afterward. 
Dr.  Warren  was  called  in  a  week  later ;  found  metro-peritonitis  and  a 
tumor  of  about  four  inches  in  diameter  in  the  right  groin.  The  peri- 
tonitis became  general,  and  Dr.  W.  was  in  attendance  for  fifteen  days. 
On  July  1st  the  tumor  was  in  the  median  line,  and  foetal  movements 
and  heart-sounds  distinct.  Labor  expected  about  October  28th  ;  sub- 
sequent gestation  normal.  AVas  called  October  26th,  at  11  P.M.; 
found  no  true  pains  ;  pains  apparently  abdominal,  rather  than  uterine, 
and  continuous  in  the  back  and  over  the  sides  of  the  uterus.  Foetus 
transverse,  with  head  to  right;  pulse  152.  Xo  change  for  several  days. 
Second  week  in  November  found  child  dead.  Xext  four  weeks  slight 
occasional  chills,  and  temperature  102°  for  two  or  three  nights,  but 
usually  normal.  Absolutely  no  expulsive  pains.  Cervix  reached  with 
difficulty,  and  finger  passed  through  a  long  tubular  neck,  but  foetus 
not  reached.  Cervix  absolutely  closed  from  December  21st  to  29th  ; 
pulse  120,  temperature  100°  to  102°.  Attempted  to  dilate  with  sponge 
tent,  but  could  not  pass  it  into  the  uterine  cavity.  December  30th 

I1  N.  O.  Med.  and  Surg.  Journ.,  July,  1877.  p.  35  :  also  communicated  by  operator,  1S7>.] 


DISEASES    OF    PREGNANCY.  203 

attempted  to  open  cervix  by  digital  dilatation,  and  succeeded  finally 
in  passing  a  cranioclast,  but  the  parts  closed  as  soon  as  the  dilatore 
were  removed.  Patient  in  a  profound  shock.  After  stimulating  for 
an  hour,  performed  Caesareau  section ;  hemorrhage  slight ;  peritoneum 
adherent  everywhere  to  uterus  ;  uterine  wall  one-quarter  inch  thick  ; 
child  presented  by  right  arm  and  side ;  placenta  thin  and  far  advanced 
in  fatty  degeneration ;  no  hemorrhage  on  its  removal ;  uterus  did  not 
contract ;  sutured  by  continuous  stitch  with  catgut.  Child  eight  and 
a  half  pounds.  Woman  rallied  slightly,  but  died  of  shock  in  twenty- 
eight  hours.  Drs.  T.  A.  Foster  and  S.  C.  Gordon  were  associated 
with  Dr.  Warren  in  the  management  of  the  case. 

It  would  appear  in  this  instance  of  missed  labor  that  the  changes 
produced  by  metro-peritonitis  prevented  the  natural  dilatation  of  the 
cervix  and  the  contractile  action  of  the  muscular  coat  of  the  uterus 
Possibly,  fatty  degeneration  of  the  muscular  fibres  had  taken  place, 
but  this  could  not  be  ascertained,  as  there  was  no  autopsy. 

The  Csesareaii  case  of  Dr.  Brodie  S.  Herndon,  of  Frederick sburg, 
Virginia,  operated  upon  with  success  in  1845,  bears  a  close  resemblance 
in  many  of  its  features  to  that  of  Dr.  Warren.  The  subject  was  a 
white  multipara  of  thirty,  whose  pains  of  labor  gave  place  to  the  con- 
tinuous pain  and  other  characteristic  symptoms  of  peritonitis.  This 
disease  lasted  a  month,  during  which  time  the  fluid  contents  of  the 
uterus  escaped  and  the  vaginal  discharge  became  very  offensive.  Five 
weeks  after  the  peritonitis  commenced  the  os  uteri  admitted  two  fingers, 
and  attempts  at  dilatation  were  made,  but  failed.  Under  ergot  an 
offensive  placenta  was  expelled,  but  the  foetus  could  not  be  removed. 
The  woman  being  greatly  wasted  and  her  room  filled  with  stench,  the 
Csesarean  operation  was  performed  on  November  16th,  forty-six  days 
after  the  first  signs  of  labor  appeared.  The  uterus  being  adherent,  the 
peritoneal  cavity  was  not  exposed  ;  the  uterus  was  sponged  out,  but  did 
not  contract;  it  was  closed  in  the  suturing  of  the  abdomen.  The 
patient  made  a  good  recovery.  As  in  the  Warren  case,  the  uterus 
became  uusuited  for  performing  the  functions  of  labor  by  reason  of 
changes  in  its  tissues  effected  by  inflammatory  action. — ED.] 


CHAPTER    VII. 

DISEASES   OF  PREGNANCY. 

THE  diseases  of  pregnancy  form  a  subject  so  extensive  that  they 
might  well  of  themselves  furnish  ample  material  for  a  separate  treatise. 
The  pregnant  woman  is,  of  course,  liable  to  the  same  diseases  as  the 
non-pregnant ;  but  it  is  only  necessary  to  allude  to  those  whose  course 


204  PREGNANCY. 

and  effects  are  essentially  modified  by  the  existence  of  pregnancy,  or 
which  have  some  peculiar  effect  on  the  patient  in  consequence  of*  her 
condition.  There  are,  moreover,  many  disorders  which  can  be  dis- 
tinctly traced  to  the  existence  of  pregnancy.  Some  of  them  are  the 
direct  results  of  the  sympathetic  irritations  which  are  then  so  commonly 
observed  ;  and,  of  these,  several  are  only  exaggerations  of  irritations 
which  may  be  said  to  be  normal  accompaniments  of  gestation.  These 
functional  derangements  may  be  classed  under  the  head  of  neuroses, 
and  they  are  sometimes  so  slight  as  merely  to  cause  temporary  incon- 
venience, at  others  so  grave  as  seriously  to  imperil  the  life  of  the 
patient.  Another  class  of  disorders  is  to  be  traced  to  local  causes  in 
connection  with  the  gravid  uterus,  and  are  either  the  mechanical 
results  of  pressure,  or  of  some  displacement  or  morbid  state  of  the 
uterus ;  while  the  origin  of  others  may  be  said  to  be  complex,  being 
partly  due  to  sympathetic  irritation,  partly  to  pressure,  and  partly  to 
obscure  nutritive  changes  produced  by  the  pregnant  state. 

Derangements  of  the  Digestive  System. — Among  the  sympa- 
thetic derangements  there  are  none  which  are  more  common,  and  none 
which  more  frequently  produce  distress,  and  even  danger,  than  those 
which  affect  the  digestive  system.  Under  the  heading  of  "  The  Signs 
of  Pregnancy,"  the  frequent  occurrence  of  nausea  and  vomiting  has 
already  been  discussed,  and  its  most  probable  causes  considered  (p.  149). 
A  certain  amount  of  nausea  is,  indeed,  so  common  an  accompaniment  of 
pregnancy  that  its  consideration  as  one  of  the  normal  symptoms  of  thai 
state  is  fully  justified.  We  need  here  only  discuss  those  cases  in  which 
the  nausea  is  excessive  and  long-continued,  and  leads  to  serious  results 
from  inanition  and  from  the  constant  distress  it  occasions.  Fortunately 
a  pregnant  woman  may  bear  a  surprising  amount  of  nausea  and  sickness 
without  constitutional  injury,  so  that  apparently  almost  all  aliments 
may  be  rejected  without  the  nutrition  of  the  body  very  materially  suf- 
fering. At  times  the  vomiting  is  limited  to  the  early  part  of  the  day, 
when  all  food  is  rejected,  and  when  there  is  a  frequent  retching  of  glairy 
transparent  fluid,  in  several  cases  mixed  with  bile,  while  at  the  latter 
part  of  the  day  the  stomach  may  be  able  to  retain  a  sufficient  quantity 
of  food,  and  the  nausea  disappears.  In  other  cases  the  nausea  and 
vomiting  are  almost  incessant.  The  patient  feels  constantly  sick,  and 
the  mere  taste  or  sight  of  food  may  bring  on  excessive  and  painful 
vomiting.  The  duration  of  this  distressing  accompaniment  of  preg- 
nancy is  also  variable.  Generally  it  commences  between  the  second 
and  third  months,  and  disappears  after  the  woman  has  quickened. 
Sometimes,  however,  it  begins  with  conception,  and  continues  unabated 
until  the  pregnancy  is  over. 

Symptoms  of  the  Graver  Cases. — In  the  worst  class  of  cases, 
when  all  nourishment  is  rejected,  and  when  the  retching  is  continuous 
and  painful,  symptoms  of  very  great  gravity,  which  may  even  prove 
fatal,  develop  themselves.  The  countenance  becomes  haggard  from 
suffering,  the  tongue  dry  and  coated,  the  epigastrium  tender  on  press- 
ure, and  a  state  of  extreme  nervous  irritability,  attended  with  restless- 
ness and  loss  of  sleep,  becomes  established.  In  a  still  more  aggravated 
degree,  there  is  general  feverishnt'ss,  with  a  rapid,  small,  and  thready 


DISEASES    OF    PREGNANCY.  205 

pulse.  Extreme  emaciation  supervenes,  the  result  of  wasting  from 
lack  of  nourishment.  The  breath  is  intensely  fetid,  and  the  tongue 
dry  and  black.  The  vomited  matters  are  sometimes  mixed  with  blood. 
The  patient  becomes  profoundly  exhausted,  a  low  form  of  delirium 
ensues,  and  death  may  follow  if  relief  is  not  obtained. 

Prognosis. — Symptoms  of  such  gravity  are  fortunately  of  extreme 
rarity,  but  they  do  from  time  to  time  arise,  and  cause  much  anxiety. 
Gueniot  collected  118  cases  of  this  form  of  the  disease,  out  of  which 
46  died ;  and  out  of  the  72  that  recovered,  in  42  the  symptoms  only 
ceased  when  abortion,  either  spontaneous  or  artificially  produced,  had 
occurred.  When  pregnancy  is  over,  the  symptoms  occasionally  cease 
with  marvellous  rapidity.  The  power  of  retaining  and  assimilating 
food  is  rapidly  regained,  and  all  the  threatening  symptoms  dis- 
appear. 

Treatment. — In  the  milder  forms  of  obstinate  vomiting,  one  of  the 
first  indications  will  be  to  remedy  any  morbid  state  of  the  primae  vise. 
The  bowels  will  not  unfrequeutly  be  found  to  be  obstinately  consti- 
pated, the  tongue  loaded,  and  the  breath  offensive;  and  when  attention 
has  been  paid  to  the  general  state  of  the  digestive  organs  by  aperient 
medicines  and  antacid  remedies,  such  as  bismuth  and  soda  and  liquor 
pepticus  after  meals,  the  tendency  to  vomiting  may  abate  without 
further  treatment. 

The  careful  regulation  of  the  diet  is  very  important.  Great  benefit 
is  often  derived  from  recommending  the  patient  not  to  rise  from  the 
recumbent  position  in  the  morning  until  she  has  taken  something. 
Half  a  cup  of  milk  and  lime-water,  or  a  cup  of  strong  coffee,  or  a 
little  rum  and  milk,  or  cocoa  and  milk,  a  glass  of  sparkling  koumiss, 
or  even  a  morsel  of  biscuit,  taken  on  waking,  often  has  a  remarkable 
effect  in  diminishing  the  nausea.  When  any  attempt  at  swallowing 
solid  food  brings  on  vomiting,  it  is  better  to  give  up  all  pretence  at 
keeping  to  regular  meals,  and  to  order  such  light  and  easily  assimilated 
food,  at  short  intervals,  as  can  be  retained.  Iced  milk,  with  lime-  or 
soda-water,  given  frequently,  and  not  more  than  a  mouthful  at  a  time, 
will  frequently  be  retained  when  nothing  else  will.  Cold  beef-jelly,  a 
spoonful  at  a  time,  will  also  be  often  kept  down.  Sparkling  koumiss 
has  been  strongly  recommended  as  very  useful  in  such  cases,  and  is 
worthy  of  trial.  It  is  well,  however,  to  bear  in  mind,  in  regulating 
the  diet,  that  the  stomach  is  fanciful  and  capricious,  and  that  the 
patient  may  be  able  to  retain  strange  and  apparently  unlikely  articles 
of  food  ;  and  that,  if  she  express  a  desire  for  such,  the  experiment  of 
letting  her  have  them  should  certainly  be  tried. 

The  medicines  that  have  been  recommended  are  innumerable,  and 
the  practitioner  will  often  have  to  try  one  after  the  other  unsuccess- 
fully ;  or  may  find,  in  an  individual  case,  that  a  remedy  will  prove 
valuable  which,  in  another,  may  be  altogether  powerless.  Amongst 
those  most  generally  useful  are  effervescing  draughts,  containing  from 
three  to  five  minims  of  dilute  hydrocyanic  acid  ;  the  creasote  mixture 
of  the  Pharmacopoeia ;  tincture  of  mix  vomica,  in  doses  of  five  or  ten 
minims ;  single  minim  doses  of  vinum  ipecacuanha?,  every  hour  in  severe 
cases,  three  or  four  times  daily  in  those  which  are  less  urgent ;  salicine, 


206  PREGNANCY. 

in  doses  of  three  to  five  grains  three  times  a  day,  recommended  by 
Tyler  Smith  ;  oxalate  of  cerium,  in  the  form  of  a  pill,  of  which  three 
to  five  grains  may  be  given  three  times  a  day — a  remedy  strongly 
advocated  by  Sir  James  Simpson,  and  which  occasionally  is  of  tin- 
doubted  service,  but  more  often  fails  ;  the  compound  pyroxylic  spirit 
of  the  London  Pharmacopoeia,  in  doses  of  five  minims  every  four 
hours,  with  a  little  compound  tincture  of  cardamom,  a  drug  which  is 
comparatively  little  known,  but  which  occasionally  has  a  very  marked 
and  beneficial  effect  in  checking  vomiting;  opiates  in  various  forms — 
which  sometimes  prove  useful,  more  often  not — may  be  administered 
either  by  the  mouth,  in  pills  containing  from  half  a  grain  to  a  grain 
of  opium,  or  in  small  doses  of  the  solution  of  the  bi-meconate  of 
morphia  or  of  Battley's  sedative  solution,  or  subcutaneously,  a  mode 
of  administration  which  is  much  more  often  successful.  The  hydro- 
chlorate  of  cocaine  is  said  to  be  very  efficacious ;  two  grains  are  dis- 
solved in  five  ounces  of  water,  by  means  of  spirit,  of  which  mixture 
a  teaspoonful  may  be  taken  every  hour.  Menthol  has  been  highly 
recommended  by  Gottshalk,1  in  doses  of  about  two  grains  every  hour. 
Antipyrine  in  ten-grain  doses  has  sometimes  proved  useful.  If  there 
is  much  tenderness  about  the  epigastrium,  one  or  two  leeches  may  be 
advantageously  applied,  or  one-third  of  a  grain  of  morphia  may  be 
sprinkled  on  the  surface  of  a  small  blister,  or  cloths  saturated  in 
laudanum  may  be  kept  over  the  pit  of  the  stomach.  The  administra- 
tion per  rectum  of  twenty  grains  of  chloral,  combined  with  the  same 
amount  of  bromide  of  potassium,  in  a  small  enema,  is  said  to  be  very 
useful.  In  many  cases  I  have  found  that  the  application  of  a  spinal 
ice-bag  to  the  cervical  vertebrae,  in  the  manner  recommended  by  Dr. 
Chapman,  has  checked  the  vomiting  when  all  drugs  have  failed.  The 
ice  may  be  placed  in  one  of  Chapman's  spinal  ice-bags,  and  applied 
for  half  an  hour  or  an  hour,  twice  or  three  times  a  day.  It  invariably 
produces  a  comforting  sensation  of  warmth,  which  is  always  agreeable 
to  the  patient.  Ice  may  be  given  to  Buck  ad  libitum,  and  is  very 
useful ;  while  if  there  be  much  exhaustion,  small  quantities  of  iced 
champagne  may  also  be  given  from  time  to  time.  The  application  of 
the  ether  spray  over  the  epigastrium  has  been  highly  recommended. 

Inasmuch  as  the  vomiting  unquestionably  has  its  origin  in  the 
uterus,  it  is  only  natural  that  practitioners  should  endeavor  to  check 
it  by  remedies  calculated  to  relieve  the  irritability  of  that  organ.  Thus 
morphia  in  the  form  of  pessaries  per  vaginam,  or  belladonna  applied 
to  the  cervix,  have  been  recommended,  and — the  former  especially — are 
often  of  undoubted  service.  A  pessary  containing  one-third  to  half  a 
grain  of  morphia  may  be  introduced  night  and  morning  without  in- 
terfering with  other  methods  of  treatment.  Dr.  Henry  Bennet  directs 
especial  attention  to  the  cervix,  which,  he  says,  is  almost  always  con- 
gested and  inflamed,  and  covered  with  granular  erosions.  This  con- 
dition he  recommends  to  be  treated  by  the  application  of  nitrate  of 
silver  through  the  speculum.  Dr.  Amand  Routh  has  recently  spoken 
highly  of  the  good  effects  of  painting  the  cervix  with  a  strong  solution 

1  Der  Frauenarzt,  March,  1891. 


DISEASES    OF    PREGNANCY.  207 

of  iodine.1  Dr.  Clay,  of  Manchester,  advocates,  especially  when  vom- 
iting continues  in  the  latter  months,  the  application  of  one  or  two 
leeches  to  the  cervix  Exception  may  fairly  be  taken  to  these  methods 
of  treatment  as  being  somewhat  hazardous,  unless  other  means  have 
been  tried  and  failed.  I  have  little  doubt,  however,  that  in  many 
cases  a  state  of  uterine  congestion  is  an  important  factor  in  keeping 
up  the  unduly  irritable  condition  of  the  uterine  fibres,  and  an  endeavor 
should  always  be  made  to  lessen  it  by  insisting  on  absolute  rest  in  the 
recumbent  posture.  Of  the  importance  of  this  precaution  in  obstinate 
cases  there  can  be  no  question.  Dr.  Copeman,  of  Norwich,  strongly 
recommended  dilatation  of  the  cervix  by  the  finger,  and  stated  that  he 
found  it  very  serviceable  in  checking  nausea.  It  is  obvious  that  this 
treatment  must  be  adopted  with  great  caution,  as,  roughly  performed, 
it  might  lead  to  the  production  of  abortion.  Dr.  Hewitt's  views  as 
to  the  dependence  of  sickness  on  flexions  of  the  uterus  have  already 
been  adverted  to,  and  reasons  have  been  given  for  doubting  the  gen- 
eral correctness  of  his  theory.  It  is  quite  likely,  however,  that  well- 
marked  displacements  of  the  uterus,  either  forward  or  backward,  may 
serve  to  intensify  the  irritability  of  the  organ.  Cazeaux  mentions  an 
obstinate  case  immediately  cured  by  replacing  a  retroverted  uterus.  A 
careful  vaginal  examination  should,  therefore,  be  instituted  in  all 
intractable  cases,  and  if  distinct  displacement  be  detected,  an  endeavor 
should  be  made  to  support  the  uterus  in  its  normal  axis.  If  retro- 
verted,  a  Hodge's  pessary  may  be  safely  employed ;  if  anteverted,  a 
small  air-ball  pessary,  as  recommended  by  Hewitt,  should  be  inserted. 
I  believe,  however,  that  such  displacements  are  the  exception,  rather 
than  the  rule,  in  cases  of  severe  sickness. 

The  importance  of  promoting  nutrition  by  every  means  in  our  power 
should  always  be  borne  in  mind.  The  effervescing  koumiss,  which  can 
now  be  readily  obtained,  I  have  found  of  great  value,  as  it  can  often 
be  retained  when  all  other  aliment  is  rejected.  The  exhaustion  pro- 
duced by  want  of  food  soon  increases  the  irritable  state  of  the  nervous 
system,  and,  if  the  stomach  will  not  retain  anything,  we  can  only 
combat  it  by  occasional  nutrient  enemata  of  strong  beef-tea,  yolk  of 
egg,  and  the  like. 

The  Production  of  Artificial  Abortion. — Finally,  in  the  worst 
class  of  cases,  when  all  treatment  has  failed,  and  when  the  patient  has 
fallen  into  the  condition  of  extreme  prostration  already  described,  we 
may  be  driven  to  consider  the  necessity  of  producing  abortion.  For- 
tunately cases  justifying  this  extreme  resource  are  of  great  rarity,  but 
nevertheless  there  is  abundant  evidence  that  every  now  and  then  women 
do  die  from  uncontrollable  vomiting  whose  lives  might  have  been  saved 
had  the  pregnancy  been  brought  to  an  end.  The  value  of  artificial 
abortion  has  been  abundantly  proved.  Indeed,  it  is  remarkable  how 
rapidly  the  serious  symptoms  disappear  when  the  uterus  is  emptied, 
and  the  tension  of  the  uterine  fibres  lessened.  It  has  fortunately  but 
rarely  fallen  to  my  lot  to  have  to  perform  this  operation  for  intractable 
vomiting.  In  one  such  case  the  patient  was  reduced  to  a  state  of  the 

i  Brit.  Med.  Journ.,  June  6, 1891. 


208  PREGNANCY. 

utmost  prostration,  having  kept  hardly  any  food  on  her  stomach  for 
many  weeks,  and  when  I  first  saw  her  she  was  lying  in  a  state  of  low 
muttering  delirium.  Within  a  few  hours  after  abortion  was  induced 
all  the  threatening  symptoms  had  disappeared,  the  vomiting  had  entirely 
ceased,  and  she  was  next  day  able  to  retain  and  absorb  all  that  was 
given  to  her.  The  value  of  the  operation,  therefore,  I  believe  to  be 
undoubted.  Where  it  has  failed  it  seems  to  have  been  on  account  of 
undue  delay.  Owing  to  the  natural  repugnance  which  all  must  feel 
toward  this  plan,  it  has  generally  been  postponed  until  the  patient  has 
been  too  exhausted  to  rally.  If,  therefore,  it  is  done  at  all,  it  should 
be  before  prostration  has  advanced  so  far  as  to  render  the  operation 
useless.  In  these  cases  the  obvious*  indication  is  to  lessen  the  tension 
of  the  uterus  at  once,  and,  therefore,  the  membranes  should  be  punc- 
tured by  the  uterine  sound,  so  as  to  let  the  liquor  amnii  drain  away, 
and  this  may  of  itself  be  sufficient  to  accomplish  the  desired  effect.  It 
is  almost  needless  to  add,  that  no  one  would  be  justified  in  resorting  to 
this  expedient  without  having  his  opinion  fortified  by  consultation  with 
a  fellow-practitioner. 

Other  disorders  of  the  digestive  system  may  give  rise  to  con- 
siderable discomfort,  but  not  to  the  serious  peril  attending  obstinate 
vomiting.  Amongst  them  are  loss  of  appetite,  acidity  and  heartburn, 
flatulent  distention,  and  sometimes  a  capricious  appetite,  which  assumes 
the  form  of  longing  for  strange  and  even  disgusting  articles  of  diet. 
Associated  with  these  conditions  there  is  generally  derangement  of  the 
whole  intestinal  tract,  indicated  by  furred  tongue  and  sluggish  bowels, 
and  they  are  best  treated  by  remedies  calculated  to  restore  a  healthy 
condition  of  the  digestive  organs,  such  as  a  light,  easily  digested  diet, 
mineral  acids,  vegetable  bitters,  occasional  aperients,  bismuth  and  soda, 
and  pepsin.  The  indications  for  treatment  are  not  different  from  those 
which  accompany  the  same  symptoms  in  the  non-pregnant  state. 

Diarrhoea  is  an  occasional  accompaniment  of  pregnancy,  often 
depending  on  errors  of  diet.  When  excessive  and  continuous  it  has  a 
decided  tendency  to  induce  uterine  contractions,  and  I  have  frequently 
observed  premature  labor  to  follow  a  sharp  attack  of  diarrhoea.  It 
should,  therefore,  not  be  neglected ;  and  if  at  all  excessive,  should  be 
checked  by  the  usual  means,  such  as  chalk  mixture  with  aromatic  con- 
fection, and  small  doses  of  laudanum  or  chlorodyne.  The  possibility 
of  apparent  diarrhoea  being  associated  with  actual  constipation,  the 
fluid  matter  finding  its  way  past  the  solid  materials  blocking  up  the 
intestines,  should  be  borne  in  mind. 

Constipation  is  much  more  common,  and  is  indeed  a  very  general 
accompaniment  of  pregnancy,  even  in  women  who  do  not  suffer  from 
it  at  other  times.  It  partly  depends  on  the  mechanical  interference  of 
the  gravid  uterus  with  the  proper  movements  of  the  intestines,  and 
partly  on  defective  innervatiou  of  the  bowels  resulting  from  the  altered 
state  of  the  blood.  The  first  indication  will  be  to  remedy  this  defect 
by  appropriate  diet,  such  as  fresh  fruits,  brown  bread,  oatmeal  por- 
ridge, etc.  Some  medicinal  treatment  will  also  be  necessary,  and,  in 
selecting  the  drugs  to  be  used,  care  should  be  taken  to  choose  such  as 
are  mild  and  unirritating  in  their  action,  and  tend  to  improve  the 


DISEASES    OF    PREGNANCY.  209 

tone  of  the  muscular  coat  of  the  intestine.  A  small  quantity  of  aperient 
mineral  water  in  the  early  morning,  such  as  the  Huuyadi*  Friedrichs- 
halle,  or  Pullua  water,  often  answers  very  well ;  or  an  occasional  dose 
of  the  confection  of  sulphur ;  or  a  pill  containing  three  or  four  grains 
of  the  extract  of  colocynth,  with  a  quarter  of  a  grain  of  the  extract  of 
mix  vornica  and  a  grain  of  extract  of  hyoscvamus,  at  bedtime ;  or  a 
teaspoonful  of  the  compound  liquorice  powder  in  milk  at  bedtime. 
Constipation  is  also  sometimes  effectually  combated  by  administering, 
twice  daily,  a  pill  containing  a  couple  of  grains  of  the  inspissated  ox- 
gall,  with  a  quarter  of  a  grain  of  extract  of  belladonna.  Enernata  of 
soap  and  water  are  often  very  useful,  and  have  the  advantage  of  not 
disturbing  the  digestion.  In  the  latter  months  of  pregnancy,  especially 
in  the  few  weeks  preceding  delivery,  the  irritation  produced  by  the 
collection  of  hardened  feces  in  the  bowel  is  a  not  infrequent  cause  of 
the  annoying  false  pains  which  then  so  commonly  trouble  the  patient. 
In  order  to  relieve  them,  it  will  be  necessary  to  empty  the  bowels 
thoroughly  by  an  aperient,  such  as  a  good  dose  of  castor  oil,  to  which 
fifteen  or  twenty  minims  of  laudanum  may  be  advantageously  added. 
Should  the  rectum  become  loaded  with  scybalous  masses,  it  may  be 
necessary  to  break  down  and  remove  them  by  mechanical  means, 
provided  we  are  unable  to  effect  this  by  copious  enemata. 

Hemorrhoids. — The  loaded  state  of  the  rectum  so  common  in  preg- 
nancy, combined  with  the  mechanical  effect  of  the  pressure  of  the 
gravid  uterus  on  the  hemorrhoidal  veins,  often  produces  very  trouble- 
some symptoms  from  piles.  In  such  cases  a  regular  and  gentle  evacu- 
ation of  the  bowels  should  be  secured  daily,  so  as  to  lessen  as  much  as 
possible  the  congestion  of  the  veins.  Any  of  the  aperients  already 
mentioned,  especially  the  sulphur  electuary,  may  be  used.  Dr.  For- 
dyce  Barker1  insists  that,  contrary  to  the  usual  impression,  one  of  the 
best  remedies  for  this  purpose  is  a  pill  containing  a  grain  or  a  grain 
and  a  half  of  powdered  aloes,  with  a  quarter  of  a  grain  of  extract  of 
mix  vomica,  and  that  castor  oil  is  distinctly  prejudicial,  and  apt  to 
•increase  the  symptoms.  I  have  certainly  found  it  answer  well  in 
several  cases.  When  the  piles  are  tender  and  swollen,  they  should  be 
freely  covered  with  ail  ointment  consisting  of  four  grains  of  muriate  of 
morphia  to  an  ounce  of  simple  ointment,  or  with  the  ung.  galla?  cum 
opio  of  the  Pharmacopoeia ;  and,  if  protruded,  an  attempt  should  be 
made  to  push  them  gently  above  the  sphincter,  by  which  they  are 
often  unduly  constricted.  Relief  may  also  be  obtained  by  frequent 
hot  fomentations,  and  sometimes,  when  the  piles  are  much  swollen,  it 
will  be  found  useful  to  puncture  them,  so  as  to  lessen  the  congestion, 
before  any  attempt  at  reduction  is  made. 

Ptyalisin. — A  profuse  discharge  from  the  salivary  glands  is  an  occa- 
sional distressing  accompaniment  of  pregnancy.  It  is  generally  con- 
fined to  the  early  months,  but  it  occasionally  continues  during  the 
whole  period  of  gestation,  and  resists  all  treatment,  only  ceasing  when 
delivery  is  over.  Under  such  circumstances  the  discharge  of  saliva  is 
sometimes  enormous,  amounting  to  several  quarts  a  day,  and  the  dis- 

i  The  Puerperal  Diseases,  p.  33. 
14 


210  PREGNANCY. 

tress  and  annoyance  to  the  patient  are  very  great.  In  one  case  under 
my  care  the  saliva  poured  from  the  mouth  all  day  long,  and  for  several 
months  the  patient  sat  with  a  basin  constantly  by  her  side,  incessantly 
emptying  her  mouth,  until  she  was  reduced  to  a  condition  giving  rise 
to  really  serious  anxiety.  This  profuse  salivation  is,  no  doubt,  a  purely 
nervous  disorder,  and  not  readily  controlled  by  remedies.  Astringent 
gargles,  containing  tannin  and  chlorate  of  potash,  frequent  sucking  of 
ice  or  of  tannin  lozenges,  inhalation  of  turpentine  and  creasote,  counter- 
irritation  over  the  salivary  glands  by  blisters  or  iodine,  the  continuous 
galvanic  current  applied  over  the  parotids,  the  bromides,  opium  inter- 
nally, small  doses  of  belladonna  or  atropine,  may  all  be  tried  in  turn, 
but  none  of  them  can  be  depended  on  with  any  degree  of  confidence. 

Toothache  and  Caries  of  the  Teeth. — Severe  dental  neuralgia  is 
also  a  frequent  accompaniment  of  pregnancy,  especially  in  the  early 
months.  When  purely  neuralgic,  quinine  in  tolerably  large  doses  is 
the  best  remedy  at  our  disposal ;  but  not  unfrequently  it  depends  on 
actual  caries  of  the  teeth,  and  attention  should  always  be  paid  to  the 
condition  of  the  teeth  when  facial  neuralgia  exists.  There  is  no  doubt 
that  pregnancy  predisposes  to  caries,  and  the  observation  of  this  fact 
has  given  rise  to  the  old  proverb,  "  For  every  child  a  tooth."  Mr. 
Oakley  Coles,  in  an  interesting  paper1  on  the  condition  of  the  mouth 
and  teeth  during  pregnancy,  refers  the  prevalence  of  caries  to  the  co- 
existence of  acid  dyspepsia,  causing  acidity  of  the  oral  secretions. 
There  is  much  unreasonable  dread  amongst  practitioners  as  to  inter- 
fering with  the  teeth  during  pregnancy,  and  some  recommend  that  all 
operations,  even  filling,  should  be  postponed  until  after  delivery. 
It  seems  to  me  certain  that  the  suffering  of  severe  toothache  is  likely 
to  give  rise  to  far  more  severe  irritation  than  the  operation  required 
for  its  relief,  and  I  have  frequently  seen  badly  decayed  teeth  extracted 
during  pregnancy,  and  with  only  a  beneficial  result. 

Affections  of  the  Respiratory  Org-ans. — Amongst  the  derange- 
ments of  the  respiratory  organs,  one  of  the  most  common  is  spasmodic 
cough,  which  is  often  excessively  troublesome.  Like  many  other  of 
the  sympathetic  derangements  accompanying  gestation,  it  is  purely 
nervous  in  character,  and  is  unaccompanied  by  elevated  temperature, 
quickened  pulse,  or  any  distinct  auscultatory  phenomena.  In  character 
it  is  not  unlike  whooping-cough.  The  treatment  must  obviously  be 
guided  by  the  character  of  the  cough.  Expectorants  are  not  likely  to 
be  of  service,  while  benefit  may  be  derived  from  some  of  the  anti- 
spasmodic  class  of  drugs,  such  as  belladonna,  hydrocyanic  acid,  opiates, 
or  bromide  of  potassium.  Such  remedies  may  be  tried  in  succession, 
but  will  often  be  found  to  be  of  little  value  in  arresting  the  cough. 
Dyspnoea  may  also  be  nervous  in  character,  and  sometimes  symptoms 
not  unlike  those  of  spasmodic  asthma  are  produced.  Like  the  other 
sympathetic  disorders,  it,  as  well  as  nervous  cough,  is  most  frequently 
observed  during  the  early  months.  There  is  another  form  of  dyspnoea, 
not  uncommonly  met  with,  which  is  the  mechanical  result  of  the  inter- 
ference with  the  action  of  the  diaphragm  and  lungs  by  the  pressure  of 

i  Trans,  of  the  Odontological  Society. 


DISEASES    OF    PREGNANCY.  211 

the  enlarged  uterus.  Hence  this  is  most  generally  troublesome  in  the 
latter  months,  and  continues  unrelieved  until  delivery,  or  until  the 
sinking  of  the  uterine  tunior  which  immediately  precedes  it.  Beyond 
taking  care  that  the  pressure  is  not  increased  by  tight  lacing  or  injudi- 
cious arrangement  of  the  clothes,  there  is  little  that  can  be  done  to 
relieve  this  form  of  breathlessness. 

Palpitation. — Palpitation,  like  dyspnoea,  may  be  due  either  to  sym- 
pathetic disturbance,  or  to  mechanical  interference  with  the  proper 
action  of  the  heart.  When  occurring  in  weakly  women  it  may  be 
referred  to  the  functional  derangements  which  accompany  the  chlorotic 
condition  of  the  blood  aften  associated  with  pregnancy,  and  is  then 
best  remedied  by  a  general  tonic  regimen,  and  the  administration  of 
ferruginous  preparations.  At  other  times  anti-spasmodic  remedies  may 
be  indicated,  and  it  is  seldom  sufficiently  serious  to  call  for  much 
special  treatment. 

Syncope. — Attacks  of  fainting  are  not  rare,  especially  in  delicate 
women  of  highly  developed  nervous  temperament,  and  are,  perhaps, 
most  common  at  or  about  the  period  of  quickening.  In  most  cases 
these  attacks  cannot  be  classed  as  cardiac,  but  are  more  probably 
nervous  in  character,  and  they  are  rarely  associated  with  complete 
abolition  of  consciousness.  They  rather,  therefore,  resemble  the  condi- 
tion described  by  the  older  authors  as  Leipothymia.  The  patient  lies 
in  a  semi-unconscious  condition  with  a  feeble  pulse  and  widely  dilated 
pupils,  and  this  state  lasts  for  varying  periods,  from  a  few  minutes  to 
half  an  hour  or  more.  In  one  very  troublesome  case  under  my  care 
they  often  recurred  as  frequently  as  three  or  four  times  a  day.  I  have 
observed  that  they  rarely  occur  \vhen  the  more  common  sympathetic 
phenomena  of  pregnancy,  especially  vomiting,  are  present.  Sometimes 
they  terminate  with  the  ordinary  symptoms  of  hysteria,  such  as  sob- 
bing. The  treatment  should  consist  during  the  attack  in  the  adminis- 
tration of  diffusible  stimulants,  such  as  ether,  salvolatile,  and  valerian, 
the  patient  being  placed  in  the  recumbent  position,  with  the  head  low. 
If  frequently  repeated  it  is  unadvisable  to  attempt  to  rally  the  patient 
by  the  too  free  administration  of  stimulants.  In  the  intervals  a  gener- 
ally tonic  regimen,  and  the  administration  of  ferruginous  remedies, 
are  indicated.  If  they  recur  with  great  frequency,  the  daily  applica- 
tion of  the  spinal  ice-bag  has  proved  of  much  service. 

Extreme  Anaemia  and  Chlorosis. — In  connection  with  disorders 
of  the  circulatory  system  may  be  noticed  those  which  depend  on  the 
state  of  the  blood.  The  altered  condition  of  the  blood,  which  has 
already  been  described  as  a  physiological  accompaniment  of  pregnancy 
(p.  145),  is  sometimes  carried  to  an  extent  which  may  fairly  be  called 
morbid ;  and  either  on  account  of  the  deficiency  of  blood  corpuscles, 
or  from  the  increase  in  its  watery  constituents,  a  state  of  extreme 
anaemia  and  chlorosis  may  be  developed.  This  may  be  sometimes 
carried  to  a  very  serious  extent,  the  condition  amounting  to  that 
known  as  "pernicious  anamiia."  Thus  Gusserow1  records  five  cases, 
in  which  nothing  but  excessive  anaemia  could  be  detected,  all  of  which 

i  Arch.  f.  Gyn.,  1871,  Bd.  11.  S.  218. 


PREGNANCY. 

ended  fatally.  Generally  when  such  symptoms  have  been  carried  to 
an  extreme  extent,  the  patient  has  been  in  a  state  of  chlorosis  before 
pregnancy.  In  cases  of  this  aggravated  type  the  patient  will  prob- 
ably miscarry,  and  the  induction  of  premature  labor  or  abortion  may 
even  become  imperative. 

Treatment. — The  treatment  must,  of  course,  be  calculated  to  im- 
prove the  general  nutrition,  and  enrich  the  impoverished  blood ;  a  light 
and  easily  assimilated  diet,  milk,  eggs,  beef-tea,  and  animal  food — if 
it  can  be  taken ;  attention  to  the  proper  action  of  the  bowels,  a  due 
amount  of  stimulants,  and  abundance  of  fresh  air,  will  be  the  chief 
indications  in  the  general  management  of  the  case.  Medicinally, 
ferruginous  preparations  will  be  required.  Some  practitioners  object, 
apparently  without  sufficient  reason,  to  the  administration  of  iron 
during  pregnancy,  as  liable  to  promote  abortion.  This  unfounded 
prejudice  may  probably  be  traced  to  the  supposed  emmenagogue  prop- 
erties of  the  preparations  of  iron;  but,  if  the  general  condition  of 
the  patient  indicate  such  medication,  they  may  be  administered  without 
any  fear.  Preparations  of  phosphorus,  such  as  the  phosphide  of  zinc, 
or  free  phosphorus,  also  promise  favorably,  and  are  well  worthy  of 
trial. 

Some  of  the  more  aggravated  cases  are  associated  with  a  consider- 
able amount  of  serous  effusion  into  the  cellular  tissue,  generally  limited 
to  the  lower  extremities,  but  occasionally  extending  to  the  arms,  face, 
and  neck,  and  even  producing  ascites  and  pleuritic  effusion.  Under 
the  latter  circumstances  this  complication  is,  of  course,  of  great  gravity, 
and  it  is  said  that  after  delivery  the  disappearance  of  the  serous  effusion 
may  be  accompanied  by  metastasis  of  a  fatal  character  to  the  lungs  or 
the  nervous  centres.  This  form  of  redenia  must  be  distinguished  from 
the  slight  cedematous  swelling  of  the  feet  and  legs  so  commonly  ob- 
served as  a  mechanical  result  of  the  pressure  of  the  gravid  uterus,  and 
also  from  those  cases  of  o?dema  associated  with  albuminuria.  The 
treatment  must  be  directed'to  the  cause,  while  the  disappearance  of  the 
effusion  may  be  promoted  by  the  administration  of  diuretic  drinks,  the 
occasional  use  of  saline  aperients,  and  rest  in  the  horizontal  position. 

Albuminuria. — The  existence  of  albumin  in  the  urine  of  pregnant 
women  has  for  many  years  attracted  the  attention  of  obstetricians,  and 
it  is  now  well  known  to  be  associated,  in  ways  still  imperfectly  under- 
stood, with  many  important  puerperal  diseases.  Its  presence  in  most 
cases  of  puerperal  eclampsia  was  long  ago  pointed  out  by  Lever  in 
this  country  and  Rayer  in  France,  and  its  association  with  this  disease 
gave  rise  to  the  theory  of  the  dependence  of  the  convulsion  on  uraemia, 
which  is  generally  still  entertained.  It  has  been  shown  of  late  years, 
especially  by  Braxton  Hicks,  that  this  association  is  by  no  means  so 
universal  as  was  supposed ;  or  rather,  that  in  some  cases  the  albumin- 
uria follows  and  does  not  precede  the  convulsions,  of  which  it  might 
therefore  be  supposed  to  be  the  consequence  rather  than  the  cause ;  so 
that  further  investigations  as  to  these  particular  points  are  still  required. 
Modern  researches  have  shown  that  there  is  an  intimate  connection 
between  many  other  affections  and  albuminuria;  as,  for  example, 
certain  forms  of  paralysis,  either  of  special  nerves,  as  puerperal 


DISEASES    OF    PREGNANCY.  213 

amaurosis,  or  of  the  spinal  system;  cephalalgia  and  dizziness;  puer- 
peral mania;  and  possibly  hemorrhage.  It  cannot,  therefore,  be 
doubted  that  albuminuria  in  the  pregnant  woman  is  liable,  at  any  rate, 
to  be  associated  with  grave  disease,  although  the  present  state  of  our 
knowledge  does  not  enable  us  to  define  very  distinctly  its  precise  mode 
of  action. 

The  presence  of  albumin  in  the  urine  of  pregnant  women  is  far 
from  a  rare  phenomenon.  Blot  and  Litzman  met  with  albuminuria 
in  20  per  cent,  of  pregnant  women,  which  is,  however,  far  above  the 
estimate  of  other  authors;  Fordyce  Barker1  thinks  it  occurs  in  about 
one  out  of  25  cases,  or  4  per  cent. ;  Hofmeier2  found  it  in  137  out 
of  5000  deliveries  in  the  Berlin  Gynecological  Institution,  or  2.74 
per  cent. ;  while,  more  recently,  Leopold  Meyer3  found  it  in  5.4  per 
cent,  out  of  1124  cases,  with  casts  in  2  per  cent.  As  in  most  of  these 
cases  it  rapidly  disappears  after  delivery,  it  is  obvious  that  its  presence 
must,  in  a  large  proportion  of  cases,  depend  on  temporary  causes,  and 
has  not  always  the  same  serious  importance  as  in  the  non-pregnant 
state.  This  is  further  proved  by  the  undoubted  fact  that  albumin, 
rapidly  disappearing  after  delivery,  is  often  found  in  the  urine  of 
pregnant  women  who  go  to  term,  and  pass  through  labor  without  any 
unfavorable  symptoms. 

Pressure  by  the  Gravid  Uterus. — The  obvious  facts  that  in 
pregnancy  the  vessels  supplying  the  kidneys  are  subjected  to  mechan- 
ical pressure  from  the  gravid  uterus,  and  that  congestion  of  the  venous ' 
circulation  of  those  viscera  must  necessarily  exist  to  a  greater  or  less 
degree,  suggest  that  here  we  may  find  an  explanation  of  the  frequent 
occurrence  of  albuminuria.  This  view  is  further  strengthened  by  the 
fact  that  the  albumin  rarely  appears  until  after  the  fifth  month,  and, 
therefore,  not  until  the  uterus  has  attained  a  considerable  size ;  and 
also  that  it  is  comparatively  more  frequently  met  with  in  primiparse, 
in  whom  the  resistance  of  the  abdominal  parietes,  and  consequent 
pressure,  must  be  greater  than  in  women  who  have  already  borne 
children.  It  is,  indeed,  probable  that  pressure  and  consequent  venous 
congestion  of  the  kidneys  have  an  important  influence  in  its  produc- 
tion ;  but  there  must  be,  as  a  rule,  some  other  factors  in  operation, 
since  an  equal  or  even  greater  amount  of  pressure  is  often  exerted  by 
ovarian  and  fibroid  tumors,  without  any  such  consequences.  They  are 
probably  complex.  One  important  condition  is  doubtless  the  increased 
amount  of  work  the  kidneys  have  to  do  in  excreting  the  waste  prod- 
ucts of  the  foetus,  as  well  as  those  of  the  mother.  The  increased 
arterial  tension  throughout  the  body  associated  with  hypertrophy  of 
the  heart,  known  to  exist  in  pregnancy,  also  operates  in  the  same 
direction.  But  in  the  large  majority  of  cases,  although  these  condi- 
tions are  present,  no  albuminuria  exists,  and  they  must,  therefore,  be 
looked  upon  as  predisposing  causes,  to  which  some  other  is  added 
before  the  albumin  escapes  from  the  vessels.  What  this  is  generally 
escapes  our  observation,  but  probably  any  condition  producing  sudden 

i  American  Journal  of  Obstetrics,  1878,  vol.  xi.  p.  449. 
*  Berlin,  klin.  Wochcnschr..  September,  1878. 
«  Zeitschr.  fur  Geb.  u.  Gyn.,  Band  xvi.  S.  215. 


214  PREGNANCY. 

hypersemia  of  the  kidneys,  and  giving  rise  to  a  state  analogous  to  the 
first  stage  of  Bright's  disease — such,  for  example,  as  sudden  exposure 
to  cold  and  impeded  cutaneous  action — may  be  sufficient  to  set  a  light 
to  the  match  already  prepared  by  the  existence  of  pregnancy.  It  has 
more  recently  been  pointed  out  that  a  transient  albuminuria,  disap- 
pearing in  a  few  days,  is  very  common  during  and  after  labor,  and 
probably  depends  on  a  catarrhal  condition  of  the  urinary  tract. 
Ingersten1  observed  this  in  50  out  of  153  deliveries,  and  in  15  only 
had  any  albumin  existed  before  the  confinement;  and  Meyer*  in  25 
per  cent,  out  of  11,138  women  in  labor,  with  casts  in  12  per  cent. 
In  addition  to  these  temporary  causes  it  must  not  be  forgotten  that 
pregnancy  may  supervene  in  a  patient  already  suffering  from  Bright's 
disease,  when,  of  course,  the  albumin  will  exist  in  the  urine  from  the 
commencement  of  gestation. 

The  various  diseases  associated  with  the  presence  of  albumin  in  the 
urine  will  require  separate  consideration.  Some  of  these,  especially 
puerperal  eclampsia,  are  amongst  the  most  dangerous  complications  of 
pregnancy.  Others,  such  as  paralysis,  cephalalgia,  dizziness,  may  also 
be  of  considerable  gravity.  The  precise  mode  of  their  production, 
and  whether  they  can  be  traced,  as  is  generally  believed,  to  the  reten- 
tion of  urinary  elements  in  the  blood,  either  urea  or  free  carbonate  of 
ammonia  produced  by  its  decomposition,  or  whether  the  two  are  only 
common  results  of  some  undetermined  cause,  will  be  considered  when 
we  come  to  discuss  puerperal  convulsions.  Whatever  view  may  ulti- 
mately be  taken  on  these  points,  it  is  sufficiently  obvious  that  albu- 
minuria in  a  pregnant  wroman  must  constantly  be  a  source  of  much 
anxiety,  and  must  induce  us  to  look  forward  with  considerable  appre- 
hension to  the  termination  of  the  case. 

Prognosis. — We  are  scarcely  in  possession  of  a  sufficiently  large 
number  of  observations  to  iustifv  any  verv  accurate  conclusions  as  to 

•/»»'•/ 

the  risk  attending  albuminuria  during  pregnancy,  but  it  is  certainly 
by  no  means  slight.  Hofmeier  believes  that  albumiuuria  is  a  most 
severe  complication  both  for  woman  and  child,  even  when  uncompli- 
cated with  eclampsia.  The  prognosis,  he  thinks,  depends  on  whether 
it  is  acute  in  its  onset,  that  is,  coming  on  within  a  few  days  of  labor, 
or  is  extended  over  several  weeks.  The  former  is  more  likely  to  pass 
entirely  away  after  delivery,  while  in  the  latter  there  is  more  risk  of 
the  morbid  state  of  the  kidneys  becoming  permanent,  and  leading  to 
the  establishment  of  Bright's  disease  after  the  pregnancy  is  over. 
Goubeyre  estimated  that  49  per  cent,  of  primiparse  who  have  albu- 
minuria, and  who  escape  eclampsia,  die  from  morbid  conditions  trace- 
able to  the  albuminuria.  This  conclusion  is  probably  much  exagger- 
ated, but,  if  it  even  approximate  to  the  truth,  the  danger  must  be  very 
great. 

Besides  the  ultimate  risk  to  the  mother,  albuminuria  strongly  pre- 
disposes to  abortion,  no  doubt  on  account  of  the  imperfect  nutrition  of 
the  foetus  by  blood  impoverished  by  the  drain  of  albuminous  materials 
through  the  kidneys.  This  fact  has  been  observed  by  many  writers. 

1  Zeitschrift  f.  Geburt.  u.  Gynak.,  1879,  Baud  v.  Heft  2.  »  Op.  cit. 


DISEASES    OF    PREGNANCY.  215 

A  good  illustration  of  it  is  given  by  Tanner,1  who  states  that  four  out 
of  seven  women  he  attended  suffering  from  Bright's  disease  during 
pregnancy,  aborted,  one  of  them  three  times  in  succession. 

Symptoms. — The  symptoms  accompanying  albuminuria  in  preg- 
nancy are  by  no  means  uniform  or  constantly  present.  That  which 
most  frequently  causes  suspicion  is  anasarca — not  only  the  cedematous 
swelling  of  the  lower  limbs  which  is  so  common  a  consequence  of  the 
pressure  of  the  gravid  uterus,  but  also  of  the  face  and  upper  extremi- 
ties. Any  puffiuess  or  infiltration  about  the  face,  or  any  oadema  about 
the  hands  or  arms,  should  always  give  rise  to  suspicion,  and  lead  to  a 
careful  examination  of  the  urine.  Sometimes  this  is  carried  to  an 
exaggerated  degree,  so  that  there  is  anasarca  of  the  whole  body. 

Anomalous  nervous  symptoms — such  as  headache,  transient  dizzi- 
ness, dimness  of  vision,  spots  before  the  eyes,  inability  to  see  objects 
distinctly,  sickness  in  women  not  at  other  times  suffering  from  nausea, 
sleeplessness,  irritability  of  temper — are  also  often  met  with,  some- 
times to  a  slight  degree,  at  others  very  strongly  developed,  and  should 
always  arouse  suspicion.  Indeed,  knowing  as  we  do  that  many  morbid 
states  may  be  associated  with  albuminuria,  we  should  make  a  point  of 
carefully  examining  the  urine  of  all  patients  in  whom  any  unusually 
morbid  phenomena  show  themselves  during  pregnancy. 

The  condition  of  the  urine  varies  considerably,  but  it  is  generally 
scanty  and  highly  colored,  and,  in  addition  to  the  albumin,  especially 
in  cases  in  which  the  albuminuria  has  existed  for  some  time,  we  may 
find  epithelium  cells,  tube-casts,  and  occasionally  blood  corpuscles. 

Treatment. — The  treatment  must  be  based  on  what  has  been  said 
as  to  the  causes  of  the  albumiuuria.  Of  course,  it  is  out  of  our  power 
to  remove  the  pressure  of  the  gravid  uterus,  except  by  inducing  labor ; 
but  its  effects  may  at  least  be  lessened  by  remedies  tending  to  promote 
an  increased  secretion  of  urine,  and  thus  diminishing  the  congestion 
of  the  renal  vessels.  The  administration  of  saline  diuretics,  such  as 
the  acetate  of  potash,  or  bitartrate  of  potash,  the  latter  being  given 
in  the  form  of  the  well-known  imperial  drink,  will  best  answer  this 
indication.  The  action  of  the  bowels  may  be  excited  by  purgatives 
producing  watery  motions,  such  as  occasional  doses  of  compound  jalap 
powder.  Dry  cupping  over  the  loins,  frequently  repeated,  has  a  bene- 
ficial effect  in  lessening  the  renal  hyperaemia.  The  action  of  the  skin 
should  also  be  promoted  by  the  use  of  the  vapor  bath,  and  with  this 
view  the  Turkish  bath  may  be  employed  with  great  benefit  and  perfect 
safety.  Jaborandi  and  pilocarpin  have  been  given  for  this  purpose, 
but  have  been  found  by  Fordyce  Barker  to  produce  a  dangerous  degree 
of  depression.  The  next  indication  is  to  improve  the  condition  of  the 
blood  by  appropriate  diet  and  medication.  A  very  light  and  easily 
assimilated  diet  should  be  ordered,  of  which  milk  should  form  the 
staple.  Tarnu-r2  has  recorded  several  cases  in  which  a  purely  milk 
diet  was  very  successful  in  removing  albuminuria.  With  the  milk, 
which  should  be  skimmed,  we  may  allow  white  of  egg,  or  a  little  white 
fish.  The  tincture  of  the  perchloride  of  iron  is  the  best  medicine  we 

1  Signs  and  Diseases  of  Pregnancy,  p.  428. 

2  Annal.  de  Gynec.,  1876,  torn.  v.  p.  41. 


216  PREGNANCY. 

can  give,  and  it  may  be  advantageously  combined  with  small  doses  of 
tincture  of  digitalis,  which  acts  as  an  excellent  diuretic. 

Finally,  in  obstinate  cases  we  shall  have  to  consider  the  advisability 
of  inducing  premature  labor.  The  propriety  of  this  procedure  in  the 
albuminuria  of  pregnancy  has  of  late  years  been  much  discussed. 
Spiegel  berg1  is  opposed  to  it,  while  Barker2  thinks  it  should  only  be 
resorted  to  "  when  treatment  has  been  thoroughly  aud  perseveringly 
tried  without  success  for  the  removal  of  symptoms  of  so  grave  a  char- 
acter that  their  continuance  would  result  in  the  death  of  the  patient." 
Hofmeier,3  on  the  other  hand,  is  -in  favor  of  the  operation,  which  he 
does  not  think  increases  the  risk  of  eclampsia,  and  may  avert  it 
altogether.  I  believe  that,  having  in  view  the  undoubted  risks  which 
attend  this  complication,  the  operation  is  unquestionably  indicated, 
and  is  perfectly  justifiable,  in  all  cases  attended  with  symptoms  of 
serious  gravity.  It  is  not  easy  to  lay  down  any  definite  rules  to  guide 
our  decision ;  but  I  should  not  hesitate  to  adopt  this  resource  in  all 
cases  in  which  the  quantity  of  albumin  is  considerable  and  progressively 
increasing,  and  in  which  treatment  has  failed  to  lessen  the  amount ; 
and,  above  all,  in  every  case  attended  with  threatening  symptoms, 
such  as  severe  headache,  dizziness,  or  loss  of  sight.  The  risks  of  the 
operation  are  infinitesimal  compared  with  those  which  the  patient 
would  run  in  the  event  of  puerperal  convulsions  supervening,  or 
chronic  Bright's  disease  becoming  established.  As  the  operation  is 
seldom  likely  to  be  indicated  until  the  child  has  reached  a  viable  age, 
and  as  the  albumiuuria  places  the  child's  life  in  danger,  we  are  quite 
justified  in  considering  the  mother's  safety  alone  in  determining  on  its 
performance. 

Diabetes. — The  occurrence  of  pregnancy  in  a  woman  suffering  from 
diabetes  may  lead  to  serious  consequences,  and  has  recently  been 
specially  investigated  by  Dr.  Matthews  Duncan.4  This  must  be 
carefully  distinguished  from  the  physiological  glycosuria  commonly 
present  at  the  end  of  pregnancy,  and  during  lactation.  It  is  probable 
that  diabetic  patients  are  inapt  to  conceive,  but  when  pregnancy  does 
occur  under  such  conditions,  the  case  cannot  be  considered  devoid  of 
anxiety.  From  the  cases  collected  by  Dr.  Duncan  it  would  appear 
that  pregnancy  is  very  liable  to  be  interrupted  in  its  course,  generally 
by  the  death  of  the  foetus,  which  has  very  often  occurred.  In  some 
instances  no  bad  results  have  been  observed,  while  in  others  the 
patient  has  collapsed  after  delivery.  Diabetic  coma  does  not  seem  to 
have  been  observed.  Out  of  twenty-two  pregnancies  in  diabetic 
women  four  ended  fatally,  so  that  the  mortality  is  obviously  very 
large.  Too  little  is  known  on  this  subject  to  justify  positive  rules  of 
treatment ;  but  if  the  symptoms  are  serious  and  increasing,  it  would 
probably  be  justifiable  to  induce  labor  prematurely,  so  as  to  lessen  the 
strain  to  which  the  patient's  constitution  is  subjected. 


1  Lehrbuch  der  Geburt. 

2  Amer.  Journ.  of  Obstet.,  1S78,  vol.  xi.  p.  449. 
8  Op.  cit. 

*  Obst.  Trans.,  1882,  vol.  xxiv.  p.  256. 


DISEASES    OF    PREGNANCY.  217 


CHAPTER    VIII. 

DISEASES  OF  PREGNANCY—  Continued. 

Disorders  of  the  Nervous  System. — There  are  many  disorders  of 
the  nervous  system  met  with  during  the  course  of  pregnancy.  Among 
the  most  common  are  morbid  irritability  of  temper,  or  a  state  of  mental 
despondency  and  dread  of  the  results  of  the  labor,  sometimes  almost 
amounting  to  insanity,  or  even  progressing  to  actual  mania.  These 
are  but  exaggerations  of  the  highly  susceptible  state  of  the  nervous 
system  generally  associated  with  gestation.  Want  of  sleep  is  not 
uncommon,  and,  if  carried  to  any  great  extent,  may  cause  serious 
trouble  from  the  irritability  and  exhaustion  it  produces.  In  such 
cases  we  should  endeavor  to  lessen  the  excitable  state  of  the  nerves, 
by  insisting  on  the  avoidance  of  late  hours,  overmuch  society,  exciting 
amusements,  and  the  like ;  while  it  may  be  essential  to  promote  sleep 
by  the  administration  of  sedatives,  none  answering  so  well  as  the 
chloral  hydrate,  in  combination  with  large  doses  of  bromide  of  potas- 
sium or  sodium,  which  greatly  intensify  its  hypnotic  effects. 

Severe  headaches  and  various  intense  neuralgias  are  common. 
Amongst  the  latter  the  most  frequently  met  with  are  pain  in  the 
breasts,  due  to  the  intimate  sympathetic  connection  of  the  mammae 
with  the  gravid  uterus;  and  intense  intercostal  neuralgia,  which  a 
careless  observer  might  mistake  for  pleuritic  or  inflammatory  pain. 
The  thermometer,  by  showing  that  there  is  no  elevation  of  tempera- 
ture, would  prevent  such  a  mistake.  Neuralgia  of  the  uterus  itself, 
or  severe  pains  in  the  groins  or  thighs — the  latter  being  probably  the 
mechanical  results  of  dragging  on  the  attachments  of  the  abdominal 
muscles — are  also  far  from  uncommon.  In  the  treatment  of  such 
neuralgic  aifeetions  attention  to  the  state  of  the  general  health,  and 
large  doses  of  quinine  and  ferruginous  preparations  M'henever  there  is 
much  debility,  will  be  indicated.  Locally  sedative  applications,  such 
as  belladonna  and  chloroform  liniments ;  friction  with  aconite  oint- 
ment when  the  pain  is  limited  to  a  small  space ;  and,  in  the  worst 
cases,  the  subcutaneous  injection  of  morphia,  will  be  called  for.  Those 
pains  which  apparently  depend  on  mechanical  causes  may  often  be 
best  relieved  by  lessening  the  traction  on  the  muscles,  by  wearing  a 
well-made  elastic  belt  to  support  the  uterus. 

Paralysis. — Among  the  most  interesting  of  the  nervous  diseases  are 
various  paralytic  aifections.  Almost  all  varieties  of  paralysis  have 
been  observed,  such  as  paraplegia,  hemiplegia  (complete  or  incomplete), 
facial  paralysis,  and  paralysis  of  the  nerves  of  special  sense,  giving 
rise  to  amaurosis,  deafness,  and  loss  of  taste.  Churchill  records 
twenty-two  cases  of  paralysis  during  pregnancy,  collected  by  him  from 


218  PREGNANCY. 

various  sources.  A  large  number  have  also  been  brought  together  by 
Imbert  Goubeyre,  in  an  interesting  memoir  on  the  subject,  and  others 
are  recorded  by  Fordyce  Barker,  Joulin,  and  other  authors ;  so  that 
there  can  be  no  doubt  of  the  fact  that  paralytic  affections  are  common 
during  gestation.  In  a  large  proportion  of  the  cases  recorded  the 
paralyses  have  been  associated  with  albuminuria,  and  are  doubtless 
ursemic  in  origin.  Thus  in  nineteen  cases,  related  by  Goubeyre,  albu- 
minuria was  present  in  all ;  Darcy,1  however,  found  no  albuminuria  in 
five  out  of  fourteen  cases.  The  dependency  of  the  paralysis  on  a  transient 
cause  explains  the  fact  that  in  a  large  majority  of  these  cases  it  was 
not  permanent,  but  disappeared  shortly  after  labor.  In  every  case  of 
paralysis,  whatever  be  its  nature,  special  attention  should  be  directed 
to  the  state  of  the  urine,  and,  should  it  be  found  to  be  albuminous, 
labor  should  be  at  once  induced.  This  is  clearly  the  proper  course  to 
pursue,  and  we  should  certainly  not  be  justified  in  running  the  risk 
that  must  attend  the  progress  of  a  case  in  which  so  formidable  a 
symptom  has  already  developed  itself.  When  the  cause  has  been 
removed,  the  effect  will  also  generally  rapidly  disappear,  and  the 
prognosis  is  therefore,  on  the  whole,  favorable.  Should  the  paralysis 
continue  after  delivery,  the  treatment  must  be  such  as  we  would  adopt 
in  the  non-pregnant  state  ;  and  small  doses  of  strychnia,  along  with 
faradization  of  the  affected  limbs,  would  be  the  best  remedies  at  our 
disposal. 

There  are,  however,  unquestionably  some  cases  of  puerperal  paralysis 
which  are  not  urasmic  in  their  origin,  and  the  nature  of  which  is  some- 
what obscure.  Hemiplegia  may  doubtless  be  occasioned  by  cerebral 
hemorrhage,  as  in  the  non-pregnant  state.  Other  organic  causes  of 
paralysis,  such  as  cerebral  congestion,  or  embolism,  may,  now  and 
again,  be  met  with  during  pregnancy,  but  cases  of  this  kind  must  be 
of  comparative  rarity.  Other  cases  are  functional  in  their  origin. 
Taruier  relates  a  case  of  hemiplegia  which  he  could  only  refer 'to 
extreme  anaemia.  Some,  again,  may  be  hysterical.  Paraplegia  is 
apparently  more  frequently  unconnected  with  albuminuria  than  the 
other  forms  of  paralysis ;  and  it  may  either  depend  on  pressure  of  the 
gravid  uterus  on  the  nerves  as  they  pass  through  the  pelvis,  or  on 
reflex  action,  as  is  sometimes  observed  in  connection  with  uterine 
disease.  When,  in  such  cases,  the  absence  of  albuminuria  is  ascer- 
tained by  frequent  examination  of  the  urine,  there  is  obviously  not  the 
same  risk  to  the  patient  as  in  cases  depending  on  uraemia,  and,  there- 
fore, it  may  be  justifiable  to  allow  pregnancy  to  go  on  to  term,  trusting 
to  subsequent  general  treatment  to  remove  the  paralytic  symptoms. 
As  the  loss  of  power  here  depends  on  a  transient  cause,  a  favorable 
prognosis  is  quite  justifiable.  Partial  paralysis  of  one  lower  extremity, 
generally  the  left,  sometimes  occurs,  from  pressure  of  the  foetal  occiput, 
and  may  continue  for  days,  or  Aveeks,  with  a  gradual  improvement, 
after  parturition. 

Chorea. — Chorea  is  not  infrequently  observed,  and  forms  a  serious 
complication.  It  is  generally  met  with  in  young  women  of  delicate 

»  These  de  Paris,  1877- 


DISEASES    OF    PREGNANCY.  219 

health,  and  in  the  first  pregnancy.  In  a  large  proportion  of  the  cases 
the  patient  has  already  suffered  from  the  disease  before  marriage.  On 
the  occurrence  of  pregnancy,  the  disposition  of  the  disease  again  be- 
comes evoked,  and  choreic  movements  are  re-established.  This  fact 
may  be  explained  partly  by  the  susceptible  state  of  the  nervous  system, 
partly  by  the  impoverished  condition  of  the  blood. 

Prognosis. — That  chorea  is  a  dangerous  complication  of  pregnancy 
is  apparent  by  the  fact  that  out  of  fifty-six  cases  collected  by  Dr. 
Barnes1  no  less  than  seventeen,  or  one  in  three,  proved  fatal.  Nor  is 
it  danger  to  life  alone  that  is  to  be  feared,  for  it  appears  certain  that 
chorea  is  more  apt  to  leave  permament  mental  disturbance  when  it 
occurs  during  pregnancy  than  at  other  times.  It  has  also  an  unques- 
tionable tendency  to  bring  on  abortion  or  premature  labor,  and  in  most 
cases  the  life  of  the  child  is  sacrificed. 

Treatment. — The  treatment  of  chorea  during  pregnancy  does  not 
differ  from  that  of  the  disease  under  more  ordinary  circumstances ;  and 
our  chief  reliance  will  be  placed  on  such  drugs  as  the  liquor  arsenicalis, 
bromide  of  potassium,  and  iron.  In  the  severe  form  of  the  disease, 
the  incessant  movements,  and  the  weariness  and  loss  of  sleep,  may  very 
seriously  imperil  the  life  of  the  patient,  and  more  prompt  and  radical 
measures  will  be  indicated.  If,  in  spite  of  our  remedies,  the  paroxysms 
go  on  increasing  in  severity,  and  the  patient's  strength  appears  to  be 
exhausted,  our  only  resource  is  to  remove  the  most  evident  cause  by 
inducing  labor.  Generally  the  symptoms  lessen  and  disappear  soon 
after  this  is  done.  There  can  be  no  question  that  the  operation  is  per- 
fectly justifiable,  and  may  even  be  essential  under  such  circumstances. 
It  should  be  borne  in  mind  that  the  chorea  often  recurs  in  a  subsequent 
pregnancy,  and  extra  care  should  then  always  be  taken  to  prevent  its 
development. 

Tetanus. — Tetanus  has  not  infrequently  been  observed  in  connection 
with  pregnancy  in  the  tropics,  where  the  disease  is  common.  In  tem- 
perate climates  it  is  exceedingly  rare,  and  has  been  more  often  met 
with  after  abortion  than  after  labor  at  term.  Little  is  known  of  this 
complication  of  pregnancy,  either  as  to  its  cause,  or  of  the  modifi- 
cation of  the  symptoms  which  may  show  themselves.  The  risk  to  the 
patient,  however,  is  very  great.  Out  of  thirty  cases  recorded — twenty- 
eight  by  Simpson  and  two  by  Wiltshire — only  six  recovered. 

Disorders  of  the  Urinary  Organs.  Retention  of  Urine. — Dis- 
orders of  the  urinary  organs  are  of  frequent  occurrence.  Retention  of 
urine  may  be  met  with,  and  this  is  often  the  result  of  a  retroverted 
uterus.  The  treatment,  therefore,  must  then  be  directed  to  the  removal 
of  the  cause.  This  subject  will  be  more  particularly  considered  when 
we  come  to  discuss  that  form  of  displacement  (p.  223) ;  but  we  may 
here  point  out  that  retention  of  urine,  if  long  continued,  may  not  only 
lead  to  much  distress,  but  to  actual  disease  of  the  coats  of  the  bladder. 
Several  cases  have  been  recorded  in  which  cystitis,  resulting  from 
urinary  retention  in  pregnancy,  eventually  caused  the  exfoliation  of 
the  entire  mucous  membrane  of  the  bladder,2  which  was  cast  off,  sorne- 

1  Obst.  Trans.,  1869,  vol.  x.  p.  147.  2  Ibid.,  1863,  vol.  iv.  p.  13. 


220  PREGNANCY. 

times  entire,  sometime  in  shreds,  and  occasionally  with  portions  of  the 
muscular  coat  attached  to  it.  The  possibility  of  this  formidable  accident 
should  teach  us  to  be  careful  not  to  allow  any  undue  retention  of  urine, 
but,  by  a  timely  use  of  the  catheter,  to  relieve  the  symptoms,  while 
we,  at  the  same  time,  endeavor  to  remove  the  cause. 

Irritability  of  the  bladder  is  of  frequent  occurrence.  In  the  early 
months  it  seems  to  be  the  consequence  of  sympathetic  irritation  of  the 
neck  of  the  bladder,  combined  with  pressure,  while  in  the  later  months 
it  is,  probably,  solely  produced  by  mechanical  causes.  When  severe 
it  leads  to  much  distress,  the  patient's  rest  being  broken  and  disturbed 
by  incessant  calls  to  micturate,  and  the  suffering  induced  may  produce 
serious  constitutional  disturbances.  I  have  elsewhere  pointed  out1  that 
irritability  of  the  bladder  in  the  later  months  of  pregnancy  is  frequently 
associated  with  an  abnormal  position  of  the  foetus,  which  is  placed 
transversely  or  obliquely.  The  result  is  either  that  undue  pressure  is 
applied  to  the  bladder,  or  that  it  is  drawn  out  of  its  proper  position. 
The  abnormal  position  of  the  fetus  can  be  easily  detected  by  palpation, 
and  is  readily  altered  by  external  manipulation. '  In  some  of  the  cases 
I  have  recorded,  altering  the  position  of  the  foetus  was  immediately 
followed  by  relief;  the  symptoms  recurring  after  a  time,  when  the 
foetus  had  again  assumed  an  oblique  position.  Should  the  foetus  fre- 
quently become  displaced,  an  endeavor  may  be  made  to  retain  it  in  the 
longitudinal  axis  of  the  uterus  by  a  proper  adaptation  of  bandages  and 
pads.  In  cases  not  referable  to  this  cause  we  should  attempt  to  relieve 
the  bladder  symptoms  by  appropriate  medication,  such  as  small  doses 
of  liquor  potassse,  if  the  urine  be  very  acid  ;  tincture  of  belladonna ; 
the  decoction  of  triticum  repens,  an  old  but  very  serviceable  remedy  ; 
and  vaginal  sedative  pessaries  containing  morphia  or  atropine. 

Women  who  have  borne  many  children  are  often  troubled  with 
incontinence  of  urine  during  pregnancy,  the  water  dribbling  away  on 
the  slightest  movement.  Through  this  much  irritation  of  the  skin 
surrounding  the  genitals  is  produced,  attended  with  troublesome  exco- 
riations and  eruptions.  Relief  may  be  partially  obtained  by  lessening 
the  pressure  on  the  bladder  by  an  abdominal  belt,  while  the  skin  is 
protected  by  applications  of  simple  ointment  or  vaseline. 

Dr.  Tyler  Smith  has  directed  attention  to  a  phosphatic  condition  of 
the  urine  occurring  in  delicate  women,  whose  constitutions  are  severely 
tried  by  gestation.  This  condition  can  easily  be  altered  by  rest,  nutri- 
tious diet,  and  a  course  of  restorative  medicine,  such  as  steel,  mineral 
acids,  and  the  like. 

Leucorrhoea. — A  profuse,  whitish,  leucorrhoeal  discharge  is  very 
common  during  pregnancy,  especially  in  its  latter  half.  The  discharge 
frequently  alarms  the  patient,  but,  unless  it  is  attended  with  disagree- 
able symptoms,  it  does  not  call  for  special  treatment.  When  at  all 
excessive,  it  may  lead  to  much  irritation  of  the  vagina  and  external 
generative  organs.  The  labia  may  become  excoriated  and  covered  with 
small  aphthous  patches,  and  the  whole  vulva  may  be  hot,  swollen,  and 
tender.  Warty  growths,  similar  in  appearance  to  syphilitic  condylo- 

1  Ibid.,  1872,  vol.  xiii.  p.  42. 


DISEASES    OF    PREGNANCY.  221 

mata,  are  occasionally  developed  in  pregnant  women,  unconnected  with 
any  specific  taint,  and  associated  with  the  presence  of  an  irritating 
lencorrhoeal  discharge.  According  to  Thibierge,1  these  resist  local 
applications,  such  as  sulphate  of  copper  or  nitrate  of  silver,  but  spon- 
taneously disappear  after  delivery.  Inasmuch  as  the  leucorrhceal 
discharge  is  dependent  on  the  congested  condition  of  the  generative 
organs  accompanying  pregnancy,  we  can  hope  to  do  little  more  than 
allev-iate  it.  In  the  severer  forms,  as  has  been  pointed  out  by  Henry 
Bonnet,  the  cervix  will  be  found  to  be  abraded  or  covered  with  granular 
erosion,  and  it  may  be,  from  time  to  time,  -cautiously  touched  with  the 
nitrate  of  silver  or  a  solution  of  carbolic  acid.  Generally  speaking, 
we  must  content  ourselves  with  recommending  the  patient  to  'svash  the 
vagina  out  gently  with  diluted  Condy's  fluid ;  or  with  a  solution  of 
the  sulpho-carbolate  of  zinc,  of  the  strength  of  four  grains  to  the 
ounce  of  water ;  or  with  plain  tepid  water.  For  obvious  reasons  fre- 
quent and  strong  vaginal  douches  are  to  be  avoided,  but  a  daily  gentle 
injection,  for  the  purpose  of  ablution,  can  do  no  harm. 

Pruritus. — A  very  distressing  pruritus  of  the  vulva  is  frequently 
met  with  along  with  leucorrhoaa,  especially  when  the  discharge  is  of 
an  acrid  character,  which  in  some  cases  leads  to  intense  and  protracted 
suffering,  forcing  the  patient  to  resort  to  incessant  friction  of  the  parts. 
Pruritus,  however,  may  exist  without  leucorrhoaa,  being  apparently 
sometimes  of  a  neuralgic  character,  at  others  associated  with  aphthous 
patches  on  the  mucous  membrane,  ascarides  in  the  rectum,  or  pediculi 
in  the  hairs  of  the  mons  Veneris  and  labia.  Cases  are  even  recorded 
in  which  the  pruritic  irritation  extended  over  the  whole  body.  The 
treatment  is  difficult  and  unsatisfactory.  Various  sedative  applications 
may  be  tried,  such  as  weak  solutions  of  Goulard's  lotion ;  or  a  lotion 
composed  of  an  ounce  of  the  solution  of  the  muriate  of  morphia,  with 
a  drachm  and  a  half  of  hydrocyanic  acid,  in  six  ounces  of  water;  or 
one  formed  by  mixing  one  part  of  chloroform  with  six  of  almond  oil. 
A  very  useful  form  of  medication  consists  in  the  insertion  into  the 
vagina  of  a  pledget  of  cotton-wool,  soaked  in  equal  parts  of  the 
glycerin  of  borax  and  sulphurous  acid ;  this  may  be  inserted  at  bed- 
time, and  withdrawn  in  the  morning  by  means  of  a  string  attached  to 
it.  Smearing  the  parts  with  an  ointment  consisting  of  boracic  acid 
ajid  vaseline  often  answers  admirably.  Relief  is  also  sometimes 
afforded  by  ichthyol  ointment.  In  the  more  obstinate  cases,  the  solid 
nitrate  of  silver  may  be  lightly  brushed  over  the  vulva;  or,  as  recom- 
mended by  Tarnier,  a  solution  of  bichloride  of  mercury,  of  about  the 
strength  of  two  grains  to  the  ounce,  may  be  applied  night  and  morning. 
The  state  of  the  digestive  organs  should  always  be  attended  to,  and 
aperient  mineral  water  may  be  usefully  administered.  AVhen  the  pru- 
ritus extends  beyond  the  vulva,  or  even  in  severe  local  cases,  large 
doses  of  bromide  of  potassium,  may  perhaps  be  useful  in  lessening  the 
general  hypersesthetic  state  of  the  nerves. 

(Edema  of  the  Lower  Limbs. — Some  of  the  disorders  of  preg- 
nancy are  the  direct  results  of  the  mechanical  pressure  of  the  gravid 

i  Arch.  gen.  de  MC-d..  1856. 


222  PEEGNANCY. 

uterus.  The  most  common  of  these  are  oedema  and  a  varicose  state  of 
the  veins  of  the  lower  extremities,  or  even  of  the  vulva.  The  former 
is  of  little  consequence,  provided  we  have  assured  ourselves  that  it  is 
really  the  result  of  pressure,  and  not  of  albuminuria,  and  it  can  gener- 
ally be  relieved  by  rest  in  the  horizontal  position.  A  varicose  state  of 
the  veins  of  the  lower  limbs  is  very  common,  especially  in  multipart, 
in  whom  it  is  apt  to  continue  after  delivery.  The  varicosity  is  gener- 
ally limited  to  the  superficial  veins,  chiefly  the  saphena,  and  the  veins 
on  the  inner  surface  of  the  leg  and  thigh  ;  sometimes  the  deeper  veins 
are  also  affected,  and  this  is  said  to  be  accompanied  by  severe  pain  in 
the  sole  of  the  foot  when  the  patient  is  standing  or  walking.  Occa- 
sionally the  veins  of  the  vulva,  and  even  of  the  vagina,  are  also 
enlarged  and  varicose,  producing  considerable  swelling  of  the  external 
genitals.  Rest  in  the  recumbent  position  and  the  use  of  an  abdominal 
belt,  so  as  to  take  the  pressure  off  the  veins  as  much  as  possible,  are 
all  that  can  be  done  to  relieve  this  troublesome  complication.  If  the 
veins  of  the  legs  are  much  swollen  some  benefit  may  be  derived  from 
an  elastic  stocking  or  a  carefully  applied  bandage. 

Laceration  of  the  Veins. — Serious  and  even  fatal  consequences 
have  followed  the  accidental  laceration  of  the  swollen  veins.  When 
laceration  occurs  during  or  immediately  after  delivery — a  not  uncom- 
mon result  of  the  pressure  of  the  head — it  gives  rise  to  the  formation 
of  a  vaginal  thrombus.  It  has  occasionally  happened  from  an  acci- 
dental injury  during  pregnancy,  as  in  the  cases  recorded  by  Simpson, 
in  which  death  followed  a  kick  on  the  pudenda,  producing  laceration 
of  a  varicose  vein,  or  in  one  mentioned  by  Tarnier,  where  the  patient 
fell  on  the  edge  of  a  chair.  Severe  hemorrhage  has  followed  the  acci- 
dental rupture  of  a  vein  in  the  leg.  The  only  satisfactory  treatment 
is  pressure,  applied  directly  to  the  bleeding  parts  by  means  of  the 
finger,  or  by  compresses  saturated  in  a  solution  of  the  perchloride  of 
iron.  The  treatment  of  vaginal  thrombus  following  labor  must  be 
considered  elsewhere.  Occasionally  the  varicose  veins  inflame,  become 
very  tender  and  painful,  and  coagula  form  in  their  canals.  In  such 
cases  absolute  rest  should  be  insisted  on,  while  sedative  lotions,  such  as 
the  chloroform  and  belladonna  liniments,  should  be  applied  to  relieve 
the  pain. 

Displacements  of  the  Gravid  Uterus. — Certain  displacements  of 
the  gravid  uterus  are  met  with  which  may  give  rise  to  symptoms  of 
great  gravity. 

Prolapse,  which  is  rare,  is  almost  always  the  result  of  pregnancy 
occurring  in  a  uterus  which  had  been  previously  more  or  less  procident. 
Under  such  circumstances  the  increasing  weight  of  the  uterus  will  at 
first  necessarily  augment  the  previously  existing  tendency  to  prolapse 
of  the  womb,  which  may  come  to  protrude  partially  and  entirely 
beyond  the  vulva.  In  the  great  majority  of  cases,  as  pregnancy 
advances,  the  prolapse  cures  itself,  for  at  about  the  fourth  or  fifth 
month  the  uterus  will  rise  above  the  pelvic  brim.  It  has  been  said 
that  in  some  cases  of  complete  procidentia  pregnancy  has  gone  even 
to  term,  with  the  uterus  lying  entirely  outside  the  vulva.  Most  prob- 
ably these  cases  were  imperfectly  observed,  the  greater  part  of  the 


DISEASES    OF    PREGNANCY.  223 

uterus  being  in  reality  above  the  pelvic  brim,  a  portion  only  of  its 
lower  segment  protruding  externally ;  or,  as  has  sometimes  been  the 
case,  the  protruding  portion  has  been  an  old-standing  hypertrophic 
elongation  of  the  cervix,  the  internal  os  uteri  and  fundus  being  nor- 
mally situated.  Should  a  prolapsed  uterus  not  rise  into  the  abdominal 
cavity  as  pregnancy  advances,  serious  symptoms  will  be  apt  to  develop 
themselves ;  for,  unless  the  pelvis  be  unusually  capacious,  the  enlarging 
uterus  will  get  jammed  within  its  bony  walls,  the  rectum  and  urethra 
will  be  pressed  upon,  defecation  and  micturition  will  be  consequently 
impeded,  and  severe  pain  and  much  irritation  will  result.  In  all  prob- 
ability such  a  state  of  things  would  lead  to  abortion.  The  possibility 
of  these  consequences  should,  therefore,  teach  us  to  be  careful  in  the 
management  of  every  case  of  prolapse,  however  slight,  in  which  preg- 
nancy occurs.  Absolute  rest,  in  the  horizontal  position,  should  be 
insisted  on ;  while  the  uterus  should  be  supported  in  the  pelvis  by  a 
full-sized  Hodge's  pessary,  which  should  be  worn  until  at  least  the 
sixth  month,  when  the  uterus  would  be  fully  within  the  abdominal 
cavity.  After  delivery,  prolonged  rest  should  be  recommended,  in  the 
hope  that  the  process  of  involution  may  be  accompanied  by  a  cure  of 
the  prolapse.  There  can  be  no  doubt  that  pregnancy  carried  to  term 
affords  an  opportunity  of  curing  even  old-standing  displacements  which 
should  not  be  neglected. 

Anteversion  of  the  gravid  uterus  seldom  produces  symptoms  of 
consequence.  In  all  probability  it  is  common  enough  when  pregnancy 
occurs  in  a  uterus  which  is  more  than  usually  anteverted,  or  is  ante- 
flexed.  Under  such  circumstances,  there  is  not  the  same  risk  of  incar- 
ceration in  the  pelvic  cavity  as  in  cases  in  which  pregnancy  exists  in  a 
retroflexed  uterus;  for,  as  the  uterus  increases  in  size,  it  rises  without 
difficulty  into  the  abdominal  cavity.  In  the  early  months  the  pressure 
of  the  fundus  on  the  bladder  may  account  for  the  irritability  of  that 
viscus  then  so  commonly  observed.  It  will  be  remembered  that  Graily 
Hewitt  attributes  great  importance  to  this  condition  as  explaining  the 
sickness  of  pregnancy — a  theory,  however,  which  has  not  met  with 
general  acceptation. 

Extreme  anteversiou  of  the  uterus,  at  an  advanced  period  of  preg- 
nancy, is  sometimes  observed  in  multi  parse  with  very  lax  abdominal 
walls,  occasionally  to  such  an  extent  that  the  uterus  falls  completely 
forward  and  downward,  so  that  the  fundus  is  almost  on  a  level  with 
the  patient's  knees.  This  form  of  pendulous  belly  may  be  associated 
with  a  separation  of  the  recti  muscles,  between  which  the  womb  forms 
a  ventral  hernia,  covered  only  by  the  cutaneous  textures.  AVhen  labor 
comes  on,  this  variety  of  displacement  may  give  rise  to  trouble  by 
destroying  the  proper  relation  of  the  uterine  and  pelvic  axes.  The 
treatment  is  purely  mechanical,  keeping  the  patient  lying  on  her  back 
as  much  as  possible,  and  supporting  the  pendulous  abdomen  by  a  prop- 
erly adjusted  bandage.  A  similar  forward  displacement  is  observed 
in  cases  of  pelvic  deformity,  and  in  the  worst  forms,  in  rhachitic  and 
dwarfed  women,  it  exists  to  a  very  exaggerated  degree. 

Betroversion. — The  most  important  of  the  displacements,  in  con- 
sequence of  its  occasional  very  serious  results,  is  retroversiou  of  the 


PREGNANCY. 

gravid  uterus.  It  was  formerly  generally  believed  that  this  was  most 
commonly  produced  by  some  accident,  such  as  a  fall,  which  dislocated 
a  uterus  previously  in  a  normal  position.  Undue  distention  of  the 
bladder  was  also  considered  to  have  an  important  influence  in  its  pro- 
duction, by  pressing  the  uterus  backward  and  downward. 

Causes. — It  is  now  almost  universally  admitted  that,  although  the 
above-named  causes  may  possibly  sometimes  produce  it,  in  the  very 
large  proportion  of  cases  it  depends  on  pregnancy  having  occurred  in 
a  uterus  previously  retroverted  or  retroflexed.  The  merit  of  pointing 
out  this  fact  unquestionably  belongs  to  the  late  Dr.  Tyler  Smith,  and 
further  observations  have  fully  corroborated  the  correctness  of  his 
views. 

In  the  large  majority  of  cases  in  which  pregnancy  occurs  in  a  uterus 
so  displaced,  as  the  womb  enlarges  it  straightens  itself,  and  rises  into 
the  abdominal  cavity,  without  giving  any  particular  trouble;  or,  as 
not  imfrequently  happens,  the  abnormal  position  of  the  organ  inter- 
feres so  much  with  its  enlargement  as  to  produce  abortion.  Sometimes, 
however,  the  uterus  increases  without  leaving  the  pelvis  until  the  third 
or  fourth  month,  when  it  can  no  longer  be  retained  in  the  pelvic  cavity 
without  inconvenience.  It  then  presses  on  the  urethra  and  rectum, 
and  eventually  becomes  completely  incarcerated  within  the  rigid  walls 
of  the  bony  pelvis,  giving  rise  to  characteristic  symptoms. 

Symptoms. — The  first  sign  which  attracts  attention  is  generally 
some  trouble  connected  with  micturition,  in  consequence  of  pressure  on 
the  urethra.  On  examination  the  bladder  will  often  be  found  to  be 
enormously  distended,  forming  a  large,  fluctuating  abdominal  tumor, 
which  the  patient  has  lost  all  power  of  emptying.  Frequently  small 
quantities  of  urine  dribble  away,  leading  the  woman  to  believe  that 
she  has  passed  Avater,  and  thus  the  distention  is  often  overlooked. 
Sometimes  the  obstruction  to  the  discharge  of  urine  is  so  great  as  to 
lead  to  dropsical  effusion  into  the  cellular  tissue  of  the  arms  and  legs. 
This  was  very  well  marked  in  one  of  my  cases,  and  disappeared  rapidly 
after  the  bladder  had  been  emptied.  Difficulty  in  defecation,  tenesmus, 
obstinate  constipation,  and  inability  to  empty  the  bowels,  become  estab- 
lished about  the  same  time.  These  symptoms  increase,  accompanied  by 
some  pelvic  pain,  and  a  sense  of  weight  and  bearing  down,  until  at  last 
the  patient  applies  for  advice,  and  the  true  nature  of  the  case  is  detected. 
AVhen  the  retroversion  occurs  suddenly,  all  these  symptoms  develop 
with  great  rapidity,  and  are  sometimes  very  serious  from  the  first. 

Progress  and  Termination. — The  further  progress  is  various. 
Sometimes,  after  the  uterus  has  been  incarcerated  in  the  pelvis  for 
more  or  less  time,  it  may  spontaneously  rise  into  the  abdominal  cavity, 
when  all  threatening  symptoms  will  disappear.  So  happy  a  termina- 
tion is  quite  exceptional,  and  should  the  practitioner  not  interfere  and 
effect  reposition  of  the  organ,  serious  and  even  fatal  consequences  may 
ensue,  unless  abortion  occurs. 

The  extreme  distention  of  the  bladder,  and  the  impossibility  of 
relieving  it,  may  lead  to  lacerations  of  its  coats  and  fatal  peritonitis  ; 
or  the  retention  of  urine  may  produce  cystitis,  with  exfoliation  of  the 
coats  of  the  bladder ;  or,  as  more  commonly  happens,  retention  of 


DISEASES    OF    PREGNANCY.  225 

urinary  elements  may  take  place,  and  death  occur  with  all  the  symp- 
toms of  ursemic  poisoning.  At  other  times  the  impacted  uterus 
becomes  congested  and  inflamed,  and  eventually  sloughs,  its  contents, 
if  the  patient  survive,  being  discharged  by  fistulous  communications 
into  the  rectum  and  vagina.  It  need  hardly  be  said  that  such  termi- 
nations are  only  possible  in  cases  which  have  been  grossly  mismanaged, 
or  the  nature  of  which  has  not  been  detected  till  a  late  period. 

Diagnosis. — The  diagnosis  is  not  difficult.  On  making  a  vaginal 
examination,  the  finger  impinges  on  a  smooth  round  elastic  swelling, 
filling  up  the  lower  part  of  the  pelvis,  stretching  and  depressing  the 
posterior  vaginal  wall,  which  occasionally  protrudes  beyond  the  vulva. 
On  passing  the  finger  fonvard  and  upward  we  shall  generally  be  able 
to  reach  the  cervix,  high  up  behind  the  pubes,  and  pressing  on  the 
urethral  canal.  In  very  complete  retroversion  it  may  be  difficult  or 
impossible  to  reach  the  cervix  at  all.  On  abdominal  examination  the 
fuudus  uteri  cannot  be  felt  above  the  pelvic  brim ;  this,  as  the  retro- 
version  does  not  give  rise  to  serious  symptoms  until  between  the  third 
and  fourth  months,  should,  under  natural  circumstances,  always  be 
possible.  By  bimanual  examination  we  can  make  out,  with  due  care, 
the  alternate  relaxation  and  contraction  of  the  uterine  parietes  char- 
acteristic of  the  gravid  uterus,  and  so  differentiate  the  swelling  from 
any  other  in  the  same  situation.  The  accompanying  phenomena  of 
pregnancy  will  also  prevent  any  mistake  of  this  kind. 

In  some  few  cases  retroversion  has  been  supposed  to  go  on  to  term. 
Strictly  speaking,  this  is  impossible ;  but  in  the  supposed  examples, 
such  as  the  well-known  case  recorded  by  Oldham,  part  of  a  retroflexed 
uterus  remained  in  the  pelvic  cavity,  while  the  greater  part  developed 
in  the  abdominal  cavity.  The  uterus  is,  therefore,  divided,  as  it  were, 
into  two  portions  :  one,  which  is  the  flexed  fundus,  remaining  in  the 
pelvis,  the  other,  containing  the  greater  part  of  the  foetus,  rising  above 
it.  Under  these  circumstances,  a  tumor  in  the  vagina  would  exist  in 
combination  with  an  abdominal  tumor,  and  pregnancy  might  go  on  to 
term.  Considerable  difficulty  may  even  arise  in  labor,  but  the  mal- 
position generally  .rectifies  itself  before  it  gives  rise  to  any  serious 
results. 

Treatment. — The  treatment  of  retroversion  of  the  gravid  uterus 
should  be  taken  in  hand  as  soon  as  possible,  for  every  day's  delay 
involves  an  increase  in  the  size  of  the  uterus,  and  leads,  therefore,  to 
greater  difficulty  in  reposition.  Our  object  is  to  restore  the  natural 
direction  of  the  uterus,  by  lifting  the  fundus  above  the  promontory 
of  the  sacrum.  The  first  thing  to  be  done  is  to  relieve  the  patient  by 
emptying  the  bladder,  the  retention  of  urine  having  probably  originally 
called  attention  to  the  case.  For  this  purpose  it  is  essential  to  use  a 
long  elastic  male  catheter  of  small  size,  as  the  urethra  is  too  elongated 
and  compressed  to  admit  of  the  passage  of  the  ordinary  silver  instru- 
ment. Even  then  it  may  be  extremely  difficult  to  introduce  the 
catheter,  and  sometimes  it  has  been  found  to  be  quite  impossible. 
Under  such  circumstances,  provided  reposition  cannot  be  effected 
\\ithout  it,  the  bladder  may  be  punctured  an  inch  or  two  above  the 
pubes  by  means  of  the  fine  needle  of  an  aspirator,  and  the  urine  drawn 

15 


226  PREGNANCY. 

off.  Dieulafoy's  work  on  aspiration  proves  conclusively  that  this  may 
be  done  without  risk,  and  the  operation  has  been  successfully  performed 
by  Schatz  and  others.  It  very  rarely  happens,  however,  and  in  long- 
neglected  cases  only,  that  the  withdrawal  of  the  urine  is  found  to  be 
impossible. 

The  bladder  being  emptied,  and  the  bowels  being  also  opened,  if 
possible,  by  copious  enemata,  we  proceed  to  attempt  reduction.  For 
this  purpose  various  procedures  are  adopted.  If  the  case  is  not  of  very 
long  standing,  I  am  inclined  to  think  that  the  gentlest  and  safest  plan 
is  the  continuous  pressure  of  a  caoutchouc  bag,  filled  with  water,  placed 
in  the  vagina.  The  good  effect  of  steady  and  long-continued  pressure 
of  this  kind  was  proved  by  Tyler  Smith,  who  effected  in  this  way  the 
reduction  of  an  inverted  uterus  of  long  standing,  and  it  is  not  difficult 
to  understand  that  it  may  succeed  when  a  more  sudden  and  violent 
effort  fails.  I  have  tried  this  plan  successfully  in  several  cases,  a 
pyriform  India-rubber  bag  being  inserted  into  the  vagina  and  dis- 
tended as  far  as  the  patient  could  bear  by  means  of  a  syringe.  The 
water  must  be  let  out  occasionally  to  allow  the  patient  to  empty  the 
bladder,  and  the  bag  immediately  refilled.  In  my  cases  reposition 
occurred  within  twenty-four  hours.  Barnes  has  failed  with  this 
method  ;  but  it  succeeded  so  well  in  my  cases,  and  is  so  obviously  less 
likely  to  prove  hurtful  than  forcible  reposition  with  the  hand,  that 
I  am  inclined  to  consider  it  the  preferable  procedure,  and  one  that 
should  be  tried  first.  Failing  with  the  fluid  pressure,  we  should 
endeavor  to  replace  the  uterus  in  the  following  way.  The  patient 
should  be  placed  at  the  edge  of  the  bed,  in  the  ordinary  obstetric  posi- 
tion, and  thoroughly  anaesthetized.  This  is  of  importance,  as  it  relaxes 
all  the  parts,  and  admits  of  much  freer  manipulation  than  is  otherwise 
possible.  One  or  more  fingers  of  the  left  hand  are  then  inserted  into 
the  rectum  ;  if  the  patient  be  deeply  chloroformed,  it  is  quite  possible, 
with  due  care,  even  to  pass  the  whole  hand,  and  an  attempt  is  then 
made  to  lift  or  push  the  fundus  above  the  promontory  of  the  sacrum. 
At  the  same  time  reposition  is  aided  by  drawing  down  the  cervix  with 
the  fingers  of  the  right  hand  per  vaginam.  It  has  been  insisted  that 
the  pressure  should  be  made  in  the  direction  of  one  or  other  sacro-iliac 
synchondrosis  rather  than  directly  upward,  so  that  the  uterus  may  not 
be  jammed  against  the  projection  of  the  promontory  of  the  sacrum. 
Failing  reposition  through  the  rectum,  an  attempt  may  be  made  per 
vaginam,  and  for  this  some  have  advised  the  upward  pressure  of  the 
closed  fist  passed  into  the  canal.  Others  recommend  the  hand-and- 
knee  position  as  facilitating  reposition,  but  this  prevents  the  adminis- 
tration of  chloroform,  which  is  of  more  assistance  than  any  change  of 
position  can  possibly  be.  Various  complex  instruments  have  been 
invented  to  facilitate  the  operation,  but  they  are  all  more  or  less 
dangerous,  and  are  unlikely  to  succeed  when  manual  pressure  has  failed. 

As  soon  as  the  reduction  is  accomplished,  subsequent  descent  of  the 
uterus  should  be  prevented  by  a  large-sized  Hodge's  pessary,  and  the 
patient  should  be  kept  at  rest  for  some  days,  the  state  of  the  bladder 
and  bowels  being  particularly  attended  to.  When  reposition  has  been 
fairly  effected  a  relapse  is  unlikely  to  occur. 


DISEASES    OF    PREGNANCY.  227 

In  cases  in  which  reduction  is  found  to  be  impossible,  our  only 
resource  is  the  artificial  induction  of  abortion.  Under  such  circum- 
stances this  is  imperatively  called  for.  It  is  best  effected  by  puncturing 
the  membranes,  the  discharge  of  the  liquor  amnii  of  itself  lessening 
the  size  of  the  uterus,  and  thus  diminishing  the  pressure  to  which  the 
neighboring  parts  are  subjected.  After  this,  reposition  may  be  possible, 
or  we  may  wait  until  the  foetus  is  spontaneously  expelled.  It  is  not 
always  easy  to  reach  the  os  uteri,  although  we  can  generally  do  so  with 
a  curved  uterine  sound.  If  we  cannot  puncture  the  membranes,  the 
liquor  amnii  may  be  drawn  off  through  the  uterine  walls  by  means  of 
the  aspirator,  inserted  through  either  the  rectum  or  vagina.  The 
injury  to  the  uterine  walls  thus  inflicted  is  not  likely  to  be  hurtful,  and 
the  risk  is  certainly  far  less  than  leaving  the  case  alone.  Naturally,  so 
extreme  a  measure  would  not  be  adopted  until  all  the  simpler  means 
indicated  have  been  tried  and  failed. 

Diseases  Coexisting  with  Pregnancy. — The  pregnant  woman  is, 
of  course,  liable  to  contract  the  same  diseases  as  in  the  non-pregnant 
state,  and  pregnancy  may  occur  in  women  already  the  subject  of  some 
constitutional  disease.  There  is  no  doubt  much  yet  to  be  learned  as 
to  the  influence  of  coexisting  disease  on  pregnancy.  It  is  certain  that 
some  diseases  are  but  little  modified  by  pregnancy,  and  that  others  are 
so  to  a  considerable  extent ;  and  that  the  influence  of  the  disease  on 
the  foetus  varies  much.  The  subject  is  too  extensive  to  be  entered 
into  at  any  length,  but  a  few  words  may  be  said  as  to  some  of  the 
more  important  affections  that  are  likely  to  be  met  with. 

The  eruptive  fevers  have  often  very  serious  consequences,  propor- 
tionate to  the  intensity  of  the  attack.  Of  these  variola  has  the  most 
disastrous  results,  which  are  related  in  the  writings  of  the  older 
authors,  but  which  are,  fortunately,  rarely  seen  in  these  days  of 
vaccination.  The  severe  and  confluent  forms  of  the  disease  are  almost 
certainly  fatal  to  both  the  mother  and  child.  In  the  discrete  form, 
and  in  modified  smallpox  after  vaccination,  the  patient  generally  has 
the  disease  favorably,  and  although  abortion  frequently  results,  it  does 
not  necessarily  do  so.  The  effects  on  the  children  vary.  The  foetus 
may  escape  the  disease  altogether ;  or  it  may  be  attacked  by  it  either 
before  or  after  birth  ;  or,  if  the  mother  has  had  smallpox  during  preg- 
nancy, thec  ':ild  maybe  subsequently  insusceptible  to  the  vaccine  virus. 

Scarlet  Fever. — If  scarlet  fever  of  an  intense  character  attacks  a 
pregnant  M'oman,  abortion  is  likely  to  occur,  and  the  risks  to  the 
mother  are  very  great.  The  milder  cases  run  their  course  without 
the  production  of  any  untoward  symptoms.  Should  abortion  occur, 
the  well-known  dangerous  effect  of  this  zymotic  disease  after  delivery 
will  gravely  influence  the  prognosis.  Cazeaux  was  of  opinion  that  preg- 
nant women  are  not  apt  to  contract  the  disease.  It  has  been  thought 
that  the  poison  when  absorbed  during  pregnancy  might  remain  latent 
until  delivery,  when  its  characteristic  effects  were  produced.  It  is 
certainly  more  common  after  delivery  than  during  pregnancy ;  thus 
Olshausen1  collected  one  hundred  and  thirty-five  cases  of  the  former 
kind,  and  only  seven  of  the  latter. 

i  Arch.  f.  Gynak.,  1877,  Bd.  ix.  S.  111. 


228  PREGNANCY. 

Measles. — Measles,  unless  very  severe,  often  runs  its  course  without 
seriously  affecting  the  mother  or  child.  I  have  myself  seen  several 
examples  of  this.  De  Tourcoing,  however,  states  that  out  of  fifteen 
cases  the  mother  aborted  in  seven,  these  being  all  very  severe  attacks. 
Some  cases  are  recorded  in  which  the  child  was  boru  with  the  rubeolous 
eruption  upon  it. 

Continued  Fevers. — The  pregnant  woman  may  be  attacked  with 
any  of  the  continued  fevers,  and  if  they  are  at  all  severe,  they  are  apt 
to 'produce  abortion.  Out  of  twenty-two  cases  of  typhoid,  sixteen 
aborted,  and  the  remaining  six,  who  had  slight  attacks,  went  on  to 
term  ;  out  of  sixty-three  cases  of  relapsing  fever,  abortion  or  premature 
labor  occurred  in  twenty-three.  According  to  Schweden  the  main 
cause  of  danger  to  the  foetus  in  continued  fevers  is  the  hyperpyrexia, 
especially  when  the  maternal  temperature  reaches  104°  or  upward. 
The  fevers  do  not  appear  to  be  aggravated  as  regards  the  mother,  and 
the  same  observation  has  been  made  by  Cazeaux  with  regard  to  this 
class  of  disease  occurring  after  delivery. 

Pneumonia. — Pneumonia  seems  to  be  specially  dangerous,  for  of 
fifteen  cases  collected  by  Grisolle1  eleven  died — a  mortality  immensely 
greater  than  that  of  the  disease  in  general.  The  larger  proportion 
also  aborted,  the  children  being  generally  dead,  and  the  fatal  result  is 
probably  due,  as  in  the  severe  continued  fevers,  to  hyperpyrexia.  The 
cause  of  the  maternal  mortality  does  not  seem  quite  apparent,  since 
the  same  danger  does  not  appear  to  exist  in  severe  bronchitis,  or  other 
inflammatory  affections. 

Phthisis. — Contrary  to  the  usually  received  opinion,  it  appears 
certain  that  pregnancy  has  no  retarding  influence  on  coexisting 
phthisis,  nor  does  the  disease  necessarily  advance  with  greater  rapidity 
after  delivery.  Out  of  twenty-seven  cases  of  phthisis,  collected  by 
Grisolle,  twenty-four  showred  the  first  symptoms  of  the  disease  after 
pregnancy  had  commenced.  Phthisical  women  are  not  apt  to  con- 
ceive ;  a  fact  which  may  probably  be  explained  by  the  frequent 
coexistence,  in  such  cases,  of  uterine  disease,  especially  severe  leucor- 
rhoea.  The  entire  duration  of  the  phthisis  seems  to  be  shortened,  as 
it  averaged  only  nine  and  a  half  months  in  the  twTenty-seven  cases 
collected — a  fact  which  proves,  at  least,  that  pregnancy  has  no  material 
influence  in  arresting  its  progress.  If  we  consider  the  tax  on  the  vital 
powers  which  pregnancy  naturally  involves,  we  must  admit  that  this 
view  is  more  physiologically  probable  than  the  one  generally  received, 
and  apparently  adopted  without  any  due  grounds. 

Heart  Disease. — The  evil  effects  of  pregnancy  and  parturition  on 
chronic  heart  disease  have  of  late  received  much  attention  from 
Spiegelberg,  Fritsch,  Peter,  and  other  writers.  The  subject  has  been 
ably  discussed2  in  a  series  of  elaborate  papers  by  Dr.  Angus  Mac- 
donald,  which  are  well  worthy  of  study.  Out  of  twenty-eight  cases 
collected  by  him,  seventeen,  or  60  per  cent.,  proved  fatal.  This,  no 
doubt,  is  not  altogether  a  reliable  estimate  of  the  probable  risk  of  the 

1  Arch.  gen.  de  Med.,  vol.  xiii.  p.  291. 
*  Obst  Journ.,  1877,  vol.  v.  p.  217. 


DISEASES    OF    PREGNANCY.  229 

complication  ;  but,  at  any  rate,  it  shows  the  serious  anxiety  which  the 
occurrence  of  pregnancy  in  a  patient  suffering  from  chronic  heart 
disease  must  cause.  Dr.  Macdonald  refers  the  evils  resulting  from 
pregnancy  in  connection  with  cardiac  lesions  to  two  causes :  first, 
destruction  of  that  equilibrium  of  the  circulation  which  has  been 
established  by  compensatory  arrangements ;  secondly,  the  occurrence 
of  fresh  inflammatory  lesions  upon  the  valves  of  the  heart  already 
diseased. 

The  dangerous  symptoms  do  not  usually  appear  until  after  the  first 
half  of  the  pregnancy  has  passed,  and  the  pregnancy  seldom  advances 
to  term.  The.  pathological  phenomena  generally  met  with  in  fatal 
cases  are  pulmonary  congestion,  especially  of  the  bronchial  mucous 
membrane,  and  pulmonary  oedema,  with  occasional  pneumonia  and 
pleurisy.  Mitral  stenosis  seems  to  be  the  form  of  cardiac  lesion  most 
likely  to  prove  serious,  and,  next  to  this,  aortic  incompeteucy.  The 
obvious  deduction  from  these  facts  is  that  heart  disease,  especially 
when  associated  with  serious  symptoms,  such  as  dyspnoea,  palpitation, 
and  the  like,  should  be  considered  a  strong  centra-indication  of 
marriage.  When  pregnancy  has  actually  occurred,  all  that  can  be 
done  is  to  enjoin  the  careful  regulation  of  the  life  of  the  patient,  so  as 
to  avoid  exposure  to  cold,  and  all  forms  of  severe  exertion. 

Syphilis. — The  important  influence  of  syphilis  on  the  ovum  is 
fully  considered  elsewhere  (p.  248).  As  regards  the  mother,  its  effects 
are  not  different  from  those  occurring  at  other  times.  It  need  only, 
therefore,  be  said  that,  whenever  indications  of  syphilis  in  a  pregnant 
woman  exist,  the  appropriate  treatment  should  be  at  once  instituted  and 
carried  on  during  her  gestation,  not  only  with  the  view  of  checking 
the  progress  of  the  disease,  but  in  the  hope  of  preventing  or  lessening 
the  risk  of  abortion,  or  of  the  birth  of  an  infected  infant.  So  far  from 
pregnancy  contra-indicating  mercurial  treatment,  there  rather  is  a 
reason  for  insisting  on  it  more  strongly.  As  to  the  precise  medication, 
it  is  advisable  to  choose  a  form  that  can  be  exhibited  continuously  for 
a  length  of  time  without  producing  serious  constitutional  results. 
Small  doses  of  the  bichloride  of  mercury,  such  as  one-sixteenth  of  a 
grain,  thrice  daily,  or  of  the  iodide  of  mercury,  or  of  the  hydrargyrum 
cum  creta,  in  combination  with  reduced  iron,  answer  the  purpose 
well ;  or,  in  the  early  stages  of  pregnancy,  the  mercurial  vapor  bath, 
or  cutaneous  inunction,  may  be  employed. 

Dr.  Weber,  of  St.  Petersburg,1  has  made  some  observations  showing 
the  superiority  of  the  latter  methods,  which  he  found  did  not  interfere 
with  the  course  of  pregnancy ;  the  contrary  was  the  case  when  the 
mercury  was  administered  by  the  mouth,  probably,  as  he  supposes, 
from  disturbance  of  the  digestive  system.  It  must  be  borne  in  mind 
that  in  married  women  it  may  sometimes  be  expedient  to  prescribe  an 
anti-syphilitic  course  without  their  knowledge  of  its  nature,  so  that 
inunction  is  not  always  feasible. 

Epilepsy. — The  influence  of  pregnancy  on  epilepsy  does  not  appear 
to  be  as  uniform  as  might  perhaps  be  expected.  In  some  cases  the 

i  Allgem.  Med.  Centr.  Zeit.,  Feb.  1875. 


230  PREGNANCY. 

number  and  intensity  of  the  fits  have  been  lessened,  in  others  the  dis- 
ease becomes  aggravated.  Some  cases  are  even  recorded  in  which 
epilepsy  appeared  for  the  first  time  during  gestation.  On  account  of 
the  resemblance  between  epilepsy  and  eclampsia  there  is  a  natural 
apprehension  that  a  pregnant  epileptic  may  suffer  from  convulsions 
during  delivery.  Fortunately,  this  is  by  no  means  necessarily  the 
case,  and  labor  often  goes  on  satisfactorily  without  any  attack. 

Diseases  of  the  Eye. — Certain  diseases  of  the  eye  are  observed 
during  pregnancy.  They  have  been  well  studied  by  Mr.  Power.1  One 
of  the  most  common  disturbances  of  vision  is  due  to  temporary  im- 
pairment of  accommodation,  most  generally  in  patients  who  are  natur- 
ally hypermetropic,  and  dependent  on  exhaustion  of  the  neuro-muscular 
apparatus.  The  symptoms  are  chiefly  difficulty  in  reading,  sewing,  or 
other  work  requiring  minute  vision ;  pain,  black  spots  before  the  eyes, 
lachrymation,  etc.  Suitable  convex  glasses  may  be  required,  and  with 
attention  to  the  general  health  the  symptoms  may  disappear.  Other 
diseases  more  serious  and  lasting  in  their  results  are  also  met  with. 
Mr.  Power  describes  certain  important  changes  in  the  eye  met  with  in 
cases  of  albuminuria.  The  optic  disk  is  swollen  and  congested,  and 
irregular  hemorrhages  and  white  disks  are  seen  in  the  retina.  The 
hemorrhages  he  ascribes  to  actual  rupture  of  the  vessels;  the  white 
patches  to  a  lesser  degree  of  distention,  admitting  of  the  escape  of 
Avhite  corpuscles  through  the  vascular  walls.  In  many  of  these  cases 
the  vision  was  ultimately  regained.  Another  form  of  disease  he  de- 
scribes is  "  white  atrophy  of  the  optic  disk,"  probably  following  neu- 
ritis, occurring  in  cases  in  which  there  had  been  great  loss  of  blood. 

Simple  jaundice,  having  little  serious  effect  on  the  mother,  although 
probably  tending  to  produce  abortion,  is  occasionally  met  witli  in 
pregnancy.  Such  attacks  may  be  transient,  and  may  pass  away  with- 
out being  attended  with  any  bad  consequence.  Their  production  is 
probably  favored  by  a  slight  degree  of  parenchymatous  infiltration  of 
the  liver,  which  is  a  normal  accompaniment  of  healthy  pregnancy,  as 
well  as  by  the  mechanical  pressure  of  the  gravid  uterus  on  the  intes- 
tines and  the  bile-ducts.  Their  symptoms  do  not  differ  from  those  of 
similar  attacks  in  the  non-pregnant  state. 

The  chief  anxiety  in  regard  to  jaundice  in  pregnant  women  is  that 
it  is  the  frequent  precursor  of  the  serious  disease  known  as  "  acute 
yellow  atrophy  of  the  liver,"  Avhich  is,  as  a  matter  of  fact,  a  misnomer, 
the  disease  being  a  general  one,  of  which  the  liver  changes,  though 
marked,  are  by  no  means  an  exclusive  manifestation. 

Into  the  pathology  and  symptoms  of  this  fatal  illness  it  would  be 
out  of  place  to  enter  here  at  length.  It  is  chiefly  of  moment  to  the 
obstetrician  from  the  fact  that  it  is  undoubtedly  more  common  in  preg- 
nant women  than  in  others.  This  is  to  be  explained  partly  by  the 
parenchymatous  changes  in  the  liver  natural  to  pregnancy,  partly  to 
the  impaired  action  of  the  kidneys,  and  to  the  altered  state  of  the 
blood  met  with  in  that  condition,  the  general  toxaemia,  characteristic 
of  the  disease,  being  ultimately  increased  by  the  retention  of  the  bile- 

1  Barnes  :  Obst.  Med.,  vol.  i.  p.  390. 


DISEASES    OF    PREGNANCY.  231 

products.  The  prognosis,  as  regards  the  mother,  is  as  bad  as  anything 
can  be,  very  few  cases,  and  these  of  a  doubtful  character,  having  re- 
covered. As  regards  the  foetus,  the  issue  is  also  almost  necessarily 
fatal,  and  it  has  been  noted  that  while  the  foetus  perishes  early  in  the 
course  of  the  illness,  there  is  not  the  same  tendency  for  the  uterus  to 
throw  off  its  contents  which  is  observed  in  other  conditions  in  which 
the  ovum  is  destroyed,  but  that  the  dead  and  macerated  foetus  is  retained 
in  utero. 

The  important  point  to  decide  in  a  suspected  case  is  as  to  whether 
means  should  be  taken  to  put  an  end  to  the  pregnancy  or  not.  This 
would  appear  to  be  a  reasonable  procedure,  since  the  toxic  conditions 
of  the  blood  must  go  on  increasing  paripassu  with  pregnancy.  Even 
this,  however,  is  of  doubtful  expediency,  for  it  has  been  observed  that 
previously  existing  symptoms  have  become  intensified  after  abortion, 
possibly  from  the  increased  weakness  resulting  from  the  hemorrhage 
accompanying  it.1 

Carcinoma. — The  occurrence  of  pregnancy  in  a  woman  suffering 
from  malignant  disease  of  the  uterus  is  by  no  means  so  rare  as  might 
be  supposed,  and  must  naturally  give  rise  to  much  anxiety  as  to  the 
result.  The  obstetrical  treatment  of  these  cases  will  be  discussed  else- 
where. Should  we  be  aware  of  the  existence  of  the  disease  during 
gestation,  the  question  will  arise  whether  we  should  not  attempt  to 
lessen  the  risks  of  delivery  by  bringing  on  abortion  or  premature 
labor.  The  question  is  one  which  is  by  no  means  easy  to  settle.  We 
have  to  deal  with  a  disease  which  is  certain  to  prove  fatal  to  the  mother 
before  long,  and  the  progress  of  which  is  probably  accelerated  after 
labor,  while  the  manipulations  necessary  to  induce  delivery  may  very 
unfavorably  influence  the  diseased  structures.  Again,  by  such  a 
measure  we  necessarily  sacrifice  the  child,  while  we  are  by  no  means 
certain  that  we  materially  lessen  the  danger  to  the  mother.  The  ques- 
tion cannot  be  settled  except  on  a  consideration  of  each  particular  case. 
If  we  see  the  patient  early  in  pregnancy,  by  inducing  abortion  we  may 
save  her  the  dangers  of  labor  at  term — possibly  of  the  Caesarean  sec- 
tion— if  the  obstruction  be  great.  Under  such  circumstances,  the 
operation  would  be  justifiable.  If  the  pregnancy  has  advanced  beyond 
the  sixth  or  seventh  month,  unless  the  amount  of  malignant  deposit  be 
very  small  indeed,  it  is  probable  that  the  risks  of  labor  would  be  as 
great  to  the  mother  as  at  term,  and  it  wrould  then  be  advisable  to  give 
her  the  advantage  of  the  few  months'  delay.  If  the  malignant  growth 
is  of  the  epithelial  variety,  and  limited  to  the  cervix,  it  might  in  some 
cases  be  advisable  to  operate  on  it  by  amputating  the  cervix  with  the 
Scraseur  or  galvano-caustic  wire.  This  would  probably  be  followed 
by  abortion,  which,  under  such  conditions,  would  not  be  a  disadvantage 
to  the  mother. 

Ovarian  Tumor. — Cases  are  occasionally  met  with  in  which  preg- 
nancy occurs  in  women  who  are  suffering  from  ovarian  tumor,  and 
their  proper  management  has  given  rise  to  considerable  discussion. 
There  can  be  no  doubt  that  such  cases  are  attended  with  very  dauger- 

1  Lusk's  Midwifery,  4th  edition,  p.  260. 


232  PKEGNANCY. 

ous  and  often  fatal  consequences,  for  the  abdomen  cannot  well  accom- 
modate the  gravid  uterus  and  the  ovarian  tumor,  both  increasing 
simultaneously.  The  result  is  that  the  tumor  is  subject  to  much  con- 
tusion and  pressure,  which  have  sometimes  led  to  the  rupture  of  the 
cyst,  and  the  escape  of  its  contents  into  the  peritoneal  cavity ;  at  others 
to  a  low  form  of  inflammation,  attended  with  much  exhaustion,  the 
death  of  the  patient  supervening  either  before  or  shortly  after  delivery. 
The  danger  during  delivery  from  the  same  cause,  in  the  cases  which 
go  on  to  term,  is  also  very  great.  Of  thirteen  cases  of  delivery  by  the 
natural  powers,  which  I  collected  in  a  paper  on  "  Labor  Complicated 
with  Ovarian  Tumor,"1  far  more  than  one-half  proved  fatal.  Another 
source  of  danger  is  twisting  of  the  pedicle,  and  consequent  strangula- 
tion of  the  cyst,  of  which  several  instances  are  recorded.  It  is  obvious, 
then,  that  the  risks  are  so  manifold  that  in  every  case  it  is  advisable  to 
consider  whether  they  can  be  lessened  by  surgical  treatment. 

The  means  at  our  disposal  are  either  to  induce  labor  prematurely,  to 
treat  the  tumor  by  tapping,  or  to  perform  ovariotomy.  The  question 
has  been  particularly  discussed  by  Spencer  AVells  in  his  works  on 
Ovariotomy,  and  by  Barnes  in  his  Obstetric  Operations.  The  former 
holds  that  the  proper  course  to  pursue  is  to  tap  the  tumor  when  there 
is  any  chance  of  its  being  materially  lessened  in  size  by  that  procedure, 
but  that  when  it  is  multilocular,  or  when  its  contents  are  solid,  ovari- 
otomy should  be  performed  at  as  early  a  period  of  pregnancy  as  pos- 
sible. Barnes,  on  the  other  hand,  maintains  that  the  safer  course  is  to 
imitate  the  means  by  which  Nature  often  meets  this  complication,  and 
bring  on  premature  labor  without  interfering  with  the  tumor.  He 
thinks  that  ovariotomy  is  out  of  the  question,  and  that  tapping  may 
be  insufficient  and  leave  enough  of  the  tumor  to  interfere  seriously 
with  labor.  So  far  as  recorded  cases  go,  they  unquestionably  seem  to 
show  that  tapping  is  not  more  dangerous  than  at  other  times,  and  that 
ovariotomy  may  be  practised  during  pregnancy  with  a  fair  amount  of 
success.  Wells  records  ten  cases  which  were  surgically  interfered  with. 
In  one,  tapping  was  performed,  and  in  nine  ovariotomy  ;  and  of  these 
eight  recovered,  the  pregnancy  going  on  to  term  in  five.  On  the  other 
hand,  five  cases  were  left  alone,  and  either  went  to  term,  or  spontaneous 
premature  labor  supervened ;  and  of  these,  three  died.  The  cases  are  not 
sufficiently  numerous  to  settle  the  question,  but  they  certainly  favor 
the  view  taken  by  Wells  rather  than  that  by  Barnes.  It  is  to  be 
observed  that,  unless  we  give  up  all  hope  of  saving  the  child,  and 
induce  abortion,  the  risk  of  induced  premature  labor,  when  the  preg- 
nancy is  sufficiently  advanced  to  hope  for  a  viable  child,  would  almost 
be  as  great  as  that  of  labor  at  term ;  for  the  question  of  interference 
will  only  have  to  be  considered  with  regard  to  large  tumors,  which 
would  be  nearly  as  much  affected  by  the  pressure  of  a  gravid  uterus 
at  seven  or  eight  months  as  by  one  at  term.  Small  tumors  generally 
escape  attention,  and  are  more  apt  to  be  impacted  before  the  presenting 
part  in  delivery.  The  success  of  ovariotomy  during  pregnancy  has 
certainly  been  great,  and  we  have  to  bear  in  mind  that  the  woman 

1  Obst.  Trans. ,  1867,  vol.  ix.  p.  69. 


DISEASES    OF    PREGNANCY.  233 

must  necessarily  be  subjected  to  the  risk  of  the  operation  sooner  or 
later,  so  that  we  cannot  judge  of  the  case  as  one  in  which  abortion 
terminates  the  risk.  Even  if  the  operation  should  put  an  end  to  the 
pregnancy— and  there  is  at  least  a  fair  chance  that  it  will  not  do  so — 
there  is  no  certainty  that  that  would  increase  the  risk  of  the  operation 
to  the  mother,  while  as  regards  the  child  we  should  only  have  the  same 
result  as  if  we  intentionally  produced  abortion.  On  the  whole,  then, 
it  seems  that  the  best  chance  to  the  mother,  and  certainly  the  best  to 
the  child,  is  to  resort  to  the  apparently  heroic  practice  recommended 
by  Wells.  The  determination  must,  however,  be  to  some  extent  influ- 
enced by  the  skill  and  experience  of  the  operator.  If  the  medical 
attendant  has  not  gained  that  experience  which  is  so  essential  for  a 
successful  ovariotomist,  the  interests  of  the  mother  would  be  best  con- 
sulted by  the  induction  of  abortion  at,  as  early  a  period  as  possible. 
One  or  other  procedure  is  essential ;  for,  in  spite  of  a  few  cases  in 
which  several  successive  pregnancies  have  occurred  in  women  who 
have  had  ovarian  tumors,  the  risks  are  such  as  not  to  justify  an  ex- 
pectant practice.  Should  rupture  of  the  cyst  occur,  there  can  be  no 
doubt  that  ovariotomy  should  at  once  be  resorted  to,  with  the  view  of 
removing  the  lacerated  cyst  and  its  extravasated  contents. 

Fibroid  Tumors. — Pregnancy  may  occur  in  a  uterus  in  which  there 
are  one  or  more  fibroid  tumors.  During  pregnancy  they  may  lead  to 
premature  labor  or  abortion,  to  peritonitis,  or  they  may  cause  so  much 
pain  and  discomfort  from  their  size  as  to  render  interference  imperative. 
If  they  are  situated  low  down,  and  in  a  position  likely  to  obstruct  the 
passage  of  the  foetus,  they  may  very  seriously  complicate  delivery. 
When  they  are  situated  in  the  fundus  or  body  of  the  uterus  they  may 
give  rise  to  risk  from  hemorrhage,  or  from  inflammation  of  their  own 
structure.  Inasmuch  as  they  are  structurally  similar  to  the  uterine 
walls,  they  partake  of  the  growth  of  the  uterus  during  pregnancy,  and 
frequently  increase  remarkably  in  size.  Cazeaux  says  :  "  I  have  known 
them  in  several  instances  to  acquire  a  size  in  three  or  four  months  which 
they  would  not  have  done  in  several  years  in  the  non-pregnant  condi- 
tion." Conversely,  they  share  in  the  involution  of  the  uterus  after 
delivery,  and  often  lessen  greatly  in  size,  or  even  entirely  disappear. 
Of  this  fact  I  have  elsewhere  recorded  several  curious  examples  ;l  and 
many  other  instances  of  the  complete  disappearance  of  even  large 
tumors  have  been  described  by  authors  whose  accuracy  of  observation 
cannot  be  questioned. 

The  treatment  will  vary  with  the  size  and  position  of  the  tumor,  and 
every  case  must  be  treated  on  its  own  merits,  since  it  is  not  possible  to 
lay  down  rules  that  will  apply  to  all  cases  alike.  A  full  report  of  all 
recent  cases  will  be  found  in  Dr.  John  Phillips's2  paper,  which  shows 
how  serious  the  results  often  are.  If  the  position  of  the  tumor  be  such 
as  to  to  render  it  certain  to  obstruct  delivery,  the  production  of  early 
abortion  is  perhaps  the  best  course  to  pursue.  It  is  not  without  serious 
risks,  but  probably  less  than  allowing  pregnancy  to  proceed  to  term. 

1  Obst.  Trains.,  1869,  vol.  x.  p.  102;  1872,  vol.  xiii.  p.  288  :  1877,  vol.  xix.  p.  101. 

2  "  The  Management  of  Fibro-myomata  complicating  Pregnancy  and  Labor.      Bilt.  Meet.  Jonrn., 
1888,  vol.  i.  p.  1331. 


234  PREGNANCY. 

In  several  instances,  either  the  removal  of  the  tumor  itself  by  abdom- 
inal section  (myomectomy),  or  the  removal  of  the  tumor  and  the  gravid 
uterus  (Porro's  operation),  has  been  resorted  to  on  account  of  the  grave 
concomitant  symptoms,  and  with  a  fair  measure  of  success.  If  the 
tumor  is  well  out  of  the  way,  interference  is  not  so  urgently  called 
for.  The  principal  danger  then  is  that  the  tumor  will  impede  the  post- 
partum  contraction  of  the  uterus,  and  favor  hemorrhage.  Even  if  this 
should  happen,  the  flooding  could  be  controlled  by  the  usual  means, 
especially  by  the  injection  of  the  perchloride  of  iron.  I  have  seen 
several  cases  in  which  delivery  has  taken  place  under  such  circum- 
stances without  any  untoward  accident,  The  danger  from  inflamma- 
tion and  subsequent  extrusion  of  the  fibroid  masses  would  probably  be 
as  great  after  abortion  or  premature  labor  as  after  delivery  at  term.  It 
seems,  therefore,  to  be  the  proper  rule  to  interfere  when  the  tumors  are 
likely  to  impede  delivery,  and  in  other  cases  to  allow  the  pregnancy  to 
go  on,  and  be  prepared  to  cope  with  any  complications  as  they  arise. 
The  risks  of  pregnancy  should  be  avoided  in  every  case  in  which 
uterine  fibroids  of  any  size  exist,  the  patients  being  advised  to  lead  a 
celibate  life. 


CHAPTER    IX. 

PATHOLOGY  OF  THE  DECIDUA  AND  OVUM. 

Pathology  of  the  Decidua. — Comparatively  little  is,  unfortunately, 
known  of  the  pathological  changes  which  occur  in  the  mucous  mem- 
brane of  the  uterus  during  pregnancy.  It  is  probable  that  they  are  of 
much  more  consequence  than  is  generally  believed  to  be  the  case  ;  and 
it  is  certain  that  they  are  a  frequent  cause  of  abortion. 

One  of  the  most  generally  observed  probably  depends  on  endome- 
tritis  antecedent  to  conception.  When  the  impregnated  ovule  reached 
the  uterus,  it  engrafted  itself  on  the  inflamed  mucous  membrane, 
which  was  in  an  unfit  condition  for  its  reception  and  growth.  A  not 
uncommon  result,  under  such  circumstances,  is  the  laceration  of  some 
of  the  decidual  vessels,  extravasation  of  the  blood  between  the  decidua 
and  the  uterine  walls,  and  consequent  abortion  at  an  early  stage  of 
pregnancy.  As  this  morbid  state  of  the  uterine  mucous  membrane  is 
likely  to  continue  after  abortion  is  completed,  the  same  history  repeats 
itself  on  each  impregnation,  and  thus  we  may  have  constant  early  mis- 
carriages produced.  It  does  not  necessarily  follow,  however,  that  the 
pregnancy  is  immediately  terminated  when  this  state  of  things  is 
present.  Sometimes  a  condition  of  hyperplasia  of  the  decidua  is  pro- 
duced, the  membrane  becomes  much  thickened  and  hypertrophied  in 
consequence  of  proliferation  of  its  interstitial  connective  tissue,  and 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 


235 


the  decidual  cells  are  greatly  increased  in  size  (Fig.  90).  In  other 
instances  the  internal  surface  of  the  decidua  becomes  studded  with 
rough  polypoid  growths,1  depending  on  proliferation  of  its  interstitial 
tissue,  a  condition  described  as  endometritis  decidualis  polyposa,  or 
tuberosa.  Duncan  has  found  that  the  hypertrophied  decidua  is  always 
in  a  state  of  fatty  degeneration,  more  advanced  in  some  places  than  in 
others.2  The  result  of  these  alterations  is  frequently  to  produce 
dwindling  or  death  of  the  ovum,  which,  however,  retains  its  connection 

FIG.  90. 


Hypertrophied  decidna  laid  open,  with  the  ovum  attached  to  its  fundal  portion. 
(After  DUNCAN.) 

with  the  decidua,  until,  after  a  lapse  of  time,  the  decidua  is  expelled  in 
the  form  of  a  thick  triangular  fleshy  substance,  with  the  atrophied 
ovum  attached  to  some  part  of  its  inner  surface.  In  other  cases,  in 
which  the  hyperplasia  has  advanced  to  a  less  extent,  the  nutrition  of 
the  fetus  is  not  interfered  with,  and  pregnancy  may  continue  to  term, 
the  changes  in  the  decidua  being  recognizable  after  delivery.  Other 
diseases  besides  endometritis  may  give  rise  to  similar  alterations  in  the 
decidua,  one  of  these  being,  as  Virchow  maintains,  syphilis.  ^The 
converse  condition,  an  imperfect  development  of  the  decidua,  especially 
of  the  decidua  reflexa,  has  also  been  noted  as  a  cause  of  abortion.  The 

i  Virchow's  Archiv  fur  Path.,  1861, 1st  edit. 
*  Researches  in  Obstetrics,  p.  293. 


236 


PREGNANCY 


ovum  will  then  hang  loosely  in  the  uterine  cavity  without  the  support 
which  the  growth  of  the  deeidua  reflexa  around  it  ought  to  afford,  and 
its  premature  expulsion  readily  follows  (Fig.  91). 


FIG.  91. 


Imperfectly  developed  deeidua  vera,  with  the  ovum.    (After  DUNCAN.) 

Hydrorrhcea  Gravidarum.  —  The  peculiar  condition  known  as 
hydrorrhcea  gravidarum  most  probably  depends  on  some  obscure  mor- 
bid state  of  the  uterine  mucous  membrane.  By  it  is  meant  a  discharge 
of  clear  watery  fluid  at  intervals  during  pregnancy.  It  may  happen 
at  any  period  of  gestation,  but  it  is  most  commonly  met  with  in  the 
latter  mouths.  It  may  commence  with  a  mere  dribbling,  or  there  may 
be  a  sudden  and  copious  discharge  of  fluid.  Afterward  the  watery 
fluid,  which  is  generally  of  a  pale-yellowish  color  and  transparent  like 
the  liquor  amnii,  may  continue  to  escape  at  intervals  for  many  M'eeks, 
and  sometimes  in  very  great  abundance,  so  as  to  saturate  the  patient's 
clothes.  Very  frequently  it  is  expelled  in  gushes,  and  at  night,  when 
the  patient  is  lying  quietly  in  bed  ;  its  escape  is  then  probably  due  to 
uterine  contraction. 

Many  theories  have  been  held  as  to  its  cause.  By  some  it  is 
attributed  to  the  rupture  of  a  cyst  placed  between  the  ovum  and  the 
uterine  walls ;  Baudelocque  referred  it  to  a  trausudation  of  the  liquor 
an;uii  through  the  membranes ;  while  Burgess  and  Dubois  believed  it 
to  depend  on  a  laceration  of  the  membranes  at  a  distance  from  the  os 
uteri.  Mattel  more  recently  has  attributed  it  to  the  existence  of  a  sac 
between  the  chorion  and  the  amnion.  It  may  be  that  in  some  instances 
a  single  discharge  of  fluid  may  come  from  one  of  the  two  last- 
mentioned  causes.  But  if  it  be  continuous,  or  repeated,  another  source 
must  be  sought  for.  Hegar1  maintains  that  it  is  the  result  of  abun- 
dant secretion  from  the  glands  of  the  mucous  membrane,  wrhich  are  in 
a  state  of  chronic  inflammation,  the  fluid  accumulating  between  the 

»  Monat.  f.  Geburt.,  1863,  Bd.  xxii.  S.  429. 


PATHOLOGY   OF    THE    DECIDUA    AND    OVUM. 


237 


FIG.  92. 


decidua  and  chorion,  and  escaping  through  the  os  uteri.  If  this  occur 
the  decidua  is  probably  in  an  hypertrophied  and  otherwise  morbid 
state.  Hydrorrhoea  is  chiefly  of  interest  from  the  error  of  diagnosis  to 
which  it  is  likely  to  give  rise;  for,  on  being  summoned  to  a  case  in 
which  watery  discharge  has  occurred  for  the  first  time,  we  are  naturally 
apt  to  suppose  that  the  membranes  have  ruptured,  and  that  labor  is 
imminent,  Nor  is  there  any  very  certain  means  of  deciding  if  this 
be  so.  In  hydrorrhoea,  we  find  that  pains  are  absent,  the  os  uteri 
unopened,  and  ballottement  may  be  made  out.  Even  if  the  mem- 
branes be  ruptured,  there  will  be  no  indication  for  interference  unless 
labor  has  actually  commenced ;  and  the  repetition  of  the  discharge  and 
the  continuance  of  the  pregnancy  will  soon  clear  up  the  diagnosis. 
Hydrorrhoea,  although  apt  to  alarm  the  patient,  need  not  give  rise  to 
any  anxiety.  The  pregnancy  generally  progresses  favorably  to  the 
full  period,  although  in  exceptional  cases  premature  labor  may  super- 
vene. No  treatment  is  necessary,  nor  is  there  any  that  could  have 
the  least  effect  in  controlling  the  discharge. 

Pathology  of  the  Chorion. — The  only  important  disease  of  the 
chorion  with  which  we  are  acquainted  is  the  well-known  condition 
which  is  variously  described  as  uterine  hydatids,  cystic  disease  of  the 
ovum,  hydatidi/orm  degeneration  of  the  chorion,  or  vesicular  mole.  The 
name  of  uterine  hydatids  was  long  given  to  it  on  the  supposition  that 
the  grape-like  vesicles  which  characterize 
the  disease  were  true  hydatids,  similar  to 
those  which  develop  in  the  liver  and  other 
structures.  This  idea  has  long  been  ex- 
ploded, and  it  is  now  known  as  a  certainty 
that  the  disease  originates  in  the  villi  of 
the  chorion.  The  precise  mode  and  the 
causes  of  its  production  are,  however,  not 
yet  satisfactorily  settled.  The  disease  is 
characterized  by  the  existence  in  the  cavity 
of  the  uterus  of  a  large  number  of  trans- 
lucent vesicles,  containing  a  clear  limpid 
fluid  which  has  been  found  on  analysis  to 
bear  close  resemblance  to  the  liquor  amnii. 
These  small  bladder-like  bodies,  which 
vary  in  size  from  that  of  a  millet-seed  to 
an  acorn,  are  often  described  as  resembling 
a  bunch  of  grapes  or  currants.  On  more 
minute  examination,  they  are  found  not  to 
be  each  attached  to  independent  pedicles, 
as  is  the  case  in  a  bunch  of  grapes,  but  some 
of  them  grow  from  other  vesicles,  while 
others  have  distinct  pedicles  attached  to 
th  chorion,  the  pedicles  themselves  some- 
times being  distended  by  fluid  (Fig.  92). 

This  peculiar  arrangement  of  the  vesicles  is  explained  by  their  mode 
of  growth. 

Causes. — There  has  been  considerable  discussion  as  to  the  etiology 


Hydatidlform  degeneration  of  the 
chorion. 


238  PREGNANCY. 

of  this  disease.  By  some  it  is  supposed  always  to  follow  death  of  the 
foetus ;  aud  the  whole  developmental  energy  being  expended  on  the 
chorion,  which  retains  its  attachment  to  the  decidua,  the  result  is  its 
abnormal  growtli  and  cystic  degeneration.  This  is  the  view  main- 
tained by  Gierse  and  Graily  Hewitt,  and  it  is  favored  by  the  un- 
doubted fact  that  in  almost  all  cases  the  foetus  has  entirely  disappeared, 
and  by  the  occasional  occurrence  of  cases  of  twin  conceptions  in  which 
one  chorion  has  degenerated,  the  other  remaining  healthy  until  term. 
On  the  other  hand,  it  is  maintained  that  the  starting-point  is  connected 
with  the  maternal  organism.  Virchow  thinks  it  originates  in  a,  morbid 
state  of  the  decidua ;  while  others  have  attributed  it  to  some  blood 
dyscrasia  on  the  part  of  the  mother,  such  as  syphilis.  There  are 
many  reasons  for  believing  that  causes  of  this  nature  may  originate 
the  affection.  Thus  it  is  often  found  to  occur  more  than  once  in  the 
same  person ;  and  alterations  of  a  similar  kind,  although  limited  in 
extent,  are  not  unfrequently  found  in  connection  with  the  placenta 
and  membranes  of  living  children.  On  this  theory  the  death  of  the 
foetus  is  secondary,  the  consequence  of  impaired  nutrition  from  the 
morbid  state  of  the  chorion.  The  probability  is  that  both  views  may 
be  right,  the  disease  sometimes  following  the  death  of  the  embryo,  and 
at  others  being  the  result  of  obscure  maternal  causes. 

Pathology. — The  degeneration  of  the  chorion  villi  generally  com- 
mences at  an  early  period  of  pregnancy,  before  the  placenta  has 
commenced  to  form.  In  that  case,  the  entire  superficies  of  the  chorion 
becomes  affected.  The  disease,  however,  may  not  begin  until  after  the 
greater  part  of  the  chorion  villi  have  atrophied,  and  then  it  is  limited 
to  the  placenta.  The  epithelium  of  the  villi  appears  to  be  the  part  first 
affected,  and  the  whole  interior  of  the  diseased  villus  becomes  filled 
with  cells.  The  connective  tissue  of  the  villus  undergoes  a  remarkable 
proliferation,  and  collects  in  masses  in  individual  spots,  the  remainder 
of  the  villus  being  unaffected.  By  the  growth  of  these  elements  the 
villus  becomes  distended,  and  many  of  the  cells  liquify,  the  intercel- 
lular fluid,  thus  produced,  widely  separating  the  connective  tissue,  so 
as  to  form  a  network  in  the  interior  of  the  villus.1  Thus  are  formed 
the  peculiar  grape-like  bodies  which  characterize  the  disease.  When 
once  the  degeneration  has  commenced,  the  diseased  tissue  has  a  re- 
markable power  of  increase,  so  that  it  sometimes  forms  a  mass  as  large 
as  a  child's  head,  and  several  pounds  in  weight. 

The  nutrition  of  the  altered  chorion  is  maintained  by  its  connection 
with  the  decidua,  which  is  also  generally  diseased  and  hypertrophied. 
Sometimes  the  adhesion  of  the  mass  to  the  uterine  walls  is  very  firm, 
and  may  interfere  with  its  expulsion ;  while,  in  a  few  rare  cases,  it  has 
been  found  that  the  villi  -have  forced  their  way  into  the  substance  of 
the  uterus,  chiefly  through  the  uterine  sinuses,  and  thus  caused  atrophy 
and  thinning  of  its  muscular  structure.  Cases  of  this  kind  are  related 
by  Yolkmann,  Waldeyer,2  and  Barnes,  and  it  is  obvious  that  the 
intimate  adhesion  •  thus  effected  must  seriously  add  to  the  gravity  of 
the  prognosis. 

1  Braxton  Hicks  :  Guy's  Hospital  Reports,  vol.  ii.,  3d  series,  p.  380. 
s  Virchow's  Archiv,  vol.  xliv.  p.  86. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  239 

Taking  this  view  of  the  etiology  of  this  disease,  it  is  obvious  that  it 
is  essentially  connected  with  pregnancy,  and  that  there  would  be  no 
valid  ground  for  maintaining,  as  has  sometimes  been  done,  that  it  may 
occur  independently  of  conception.  It  is  just  possible,  however,  that 
true  entozoa  may  form  in  the  substance  of  the  uterus,  which,  being 
expelled  per  vaginam,  might  be  taken  for  the  results  of  cystic  disease, 
and  thus  give  rise  to  groundless  suspicions  as  to  the  patient's  chastity. 
Hewitt  has  related  one  case  in  which  true  hydatids,  originally  formed 
in  the  liver,  had  extended  to  the  peritoneum,  and  were  about  to  burst 
through  the  vagina  at  the  time  of  death.  This  occurred  in  an  unmar- 
ried woman.  One  or  two  other  examples  of  true  hydatids  forming  in 
the  substance  of  the  uterus  are  also  recorded.  A  very  interesting  case 
is  also  related  by  Hewitt,1  in  which  undoubted  acephalocysts  were 
expelled  from  the  uterus  of  a  patient  who  ultimately  recovered.  A 
careful  examination  of  the  cyst  and  its  contents  would  show  their  true 
nature,  as  the  echinococci  heads,  with  their  characteristic  booklets, 
would  be  discoverable  by  the  microscope. 

It  is  also  possible  that  unfounded  suspicions  might  arise  from  the 
fact  of  a  patient  expelling  a  mass  of  hydatids  long  after  impregnation. 
In  the  case  of  a  widow,  or  woman  living  apart  from  her  husband, 
serious  mistakes  might  thus  be  made.  This  has  been  specially  pointed 
out  by  McClintock,2  who  says :  "  Hydatids  may  be  retained  in  utero 
for  many  months  or  years,  or  a  portion  only  may  be  expelled,  and  the 
residue  may  throw  out  a  fresh  crop  of  vesicles,  to  be  discharged  on  a 
future  occasion." 

Symptoms  and  Progress. — The  symptoms  of  cystic  disease  of  the 
ovum  are  by  no  means  well  marked.  At  first  there  is  nothing  to  point 
to  the  existence  of  any  morbid  condition,  but  as  pregnancy  advances 
its  ordinary  course  is  interfered  with.  There  is  more  general  dis- 
turbance of  the  health  than  there  ought  to  be,  and  the  reflex  irritations, 
such  as  vomiting,  may  be  unusually  developed.  The  first  physical  sign 
remarked  is  rapid  increase  of  the  uterine  tumor,  which  soon  does  not 
correspond  in  size  to  the  supposed  period  of  pregnancy.  Thus,  at  the 
third  month,  the  uterus  may  be  found  to  reach  up  to,  or  beyond,  the 
umbilicus.  About  this  time  there  generally  are  more  or  less  profuse 
watery  and  sanguineous  discharges,  which  have  been  described  as 
resembling  currant  juice.  They  no  doubt  depend  on  the  breaking 
down  and  expulsion  of  the  cysts  caused  by  painless  uterine  con- 
tractions. They  are  sometimes  excessive  in  amount,  recur  with  great 
frequency,  and  often  reduce  the  patient  extremely.  Portions  of  cysts 
may  now  generally  be  found  mingled  with  the  discharge,  and  gome- 
times  large  masses  of  them  are  expelled  from  time  to  time.  Indeed, 
the  discovery  of  portions  of  cysts  is  the  only  certain  diagnostic  sign. 
Vaginal  examination,  before  the  os  has  dilated,  will  give  no  informa- 
tion except  the  absence  of  ballottement.  An  unusual  hardness  or 
density  of  the  uterus — described  by  Leishman,  who  attributes  much 
importance  to  it,  as  "a  peculiar  doughy,  boggy  feeling" — has  been 
pointed  out  by  several  writers.  The  contour  of  the  uterine  tumor, 

1  Obst.  Trans.,  1871,  vol.  xii.  p.  237. 

»  McClintock's  Diseases  of  Women,  p.  398. 


240 


PREGNANCY. 


moreover,  is  often  irregular.  In  addition,  we,  of  course,  fail  to  dis- 
cover the  usual  auscultatory  signs  of  pregnancy.  All  this  may  aid  in 
diagnosis,  but  nothing,  except  the  presence  of  cysts  in  the  watery  bloody 
discharge,  will  enable  us  to  pronounce  with  certainty  as  to  the  nature 
of  the  disease. 

Treatment. — As  soon  as  the  diagnosis  is  established,  the  indications 
for  treatment  are  obvious.  The  sooner  the  uterus  is  cleared  of  its  con- 
tents the  better.  Ergot  may  be  given  with  advantage  to  favor  uterine 
contraction,  and  the  expulsion  of  the  diseased  ovum.  Should  this  fail, 
more  especially  if  the  hemorrhage  be  great,  the  fingers,  or  the  whole 
hand,  must  be  introduced  into  the  uterus,  and  as  much  as  possible  of 
the  mass  removed.  The  uterine  cavity  should  then  be  well  washed 
out  with  an  antiseptic  solution,  such  as  creolin  and  water,  or  water 
with  sufficient  tincture  of  iodine  dropped  into  it  to  give  it  a  sherry 
color.  As  the  os  is  likely  to  be  closed,  its  preliminary  dilatation  by 
Hegar's  dilators,  or  by  a  Barnes's  bag,  if  it  be  already  opened  to  some 
extent,  will  in  most  cases  be  required.  If  chloroform  be  then  admin- 
istered, the  remaining  steps  of  the  operation  will  be  easy.  On  account 
of  the  occasional  firm  adhesion  of  the  cystic  mass  to  the  uterus,  too 
energetic  attempts  at  complete  separation  should  be  avoided.  Any 
severe  hemorrhage  after  the  operation  can  be  controlled  by  swabbing 
out  the  uterine  cavity  with  the  perchloride  of  iron  solution. 


FIG.  93. 


Myxoma  fibrosum  of  the  placenta.    (After  STORCH.) 


Myxoma  Fibrosum. — Under  the  name  of  Myxoma  fibrosum  (Fig. 
93)  a  more  rare  degeneration  of  the  chorion  has  been  described  by 
Virchow  and  Hildebrandt,1  characterized,  not  by  vesicular,  but  fibroici 


1  Monat.  f.  Geburt.,  May,  1865. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  241 

degeneration  of  the  connective  tissue  of  the  chorion.  It  results  in  the 
enlargement  of  the  chorionic  villi  by  fibrous  hypertrophy,  forming 
distinct  tumors  in  the  placental  structure,  and  is  more  frequently  met 
with  in  the  later  than  the  earlier  periods  of  pregnancy.  It  does  not, 
therefore,  necessarily  lead  to  the  death  of  the  child.1 

Pathology  of  the  Placenta. — The  pathology  of  the  placenta  has  of 
late  years  attracted  much  attention,  and  it  has  an  important  practical 
bearing,  in  consequence  of  its  effect  on  the  child. 

Placentae  vary  considerably  in  shape.  They  may  be  crescentic,  or 
spread  over  a  considerable  surface,  in  consequence  of  the  chorion  villi 
entering  into  communication  with  a  larger  portion  of  the  decidua  than 
usual  (Placenta  membranacea).  Such  forms,  however,  are  merely  of 
scientific  interest.  The  only  anomaly  of  shape  of  any  practical  im- 
portance is  the  formation  of  what  have  been  called  placenta?  succenturice. 
These  consist  of  one  or  more  separate  masses  of  placental  tissue,  pro- 
duced by  the  development  of  isolated  patches  of  chorion  villi.  Hohl 
believes  that  they  always  form  exactly  at  the  junction  of  the  anterior 
and  posterior  walls  of  the  uterus,  which  in  early  pregnancy  is  a  mere 
line.  As  the  uterus  expands,  the  portions  of  placenta  on  each  side  of 
this  become  separated  from  each  other.  They  are  only  of  consequence 
from  the  possibility  of  their  remaining  unnoticed  in  the  uterus  after 
delivery,  and  giving  rise  to  secondary  post-partum  hemorrhage.  The 
rare  form  of  double  placenta  with  a  single  cord,  figured  in  the  accom- 
panying woodcut  (Fig.  94),  was  probably  formed  in  this  way,  and  the 
supplementary  portion,  in  such  a  case,  might  readily  escape  notice. 

The  placenta  may  also  vary  in  dimensions.  Sometimes  it  is  of 
excessive  size,  generally  when  the  child  is  unusually  big,  but  not  unfre- 
queutly  in  connection  with  hydramnios,  the  child  being  dead  and 
shrivelled.  In  other  cases  it  is  remarkably  small,  or  at  least  appears 
to  be  so.  If  the  child  be  healthy,  this  is  probably  of  no  pathological 
importance,  as  its  smallness  may  be  more  apparent  than  real,  depending 
on  its  vessels  not  being  distended  with  blood.  When  true  atrophy  of 
the  placenta  exists,  the  vitality  of  the  foetus  may  be  seriously  interfered 
with.  This  condition  may  depend  either  on  a  diseased  state  of  the 
chorion  villi,  or  of  the  decidua  in  which  they  are  implanted.2  The 
latter  is  the  more  common  of  the  two ;  and  it  generally  consists  in 
hyperplasia  of  the  connective  tissue  of  the  decidua,  which  presses  on 
the  villi  and  vessels,  and  gives  rise  to  general  or  local  atrophy.  The 
change  is  similar  in  its  nature  to  that  observed  in  cirrhosis  of  the  liver, 
and  certain  forms  of  Bright's  disease.  It  has  been  specially  studied 
by  Hegar  and  Miiier,3  who  describe  it  as  beginning  with  a  development 
of  the  elongated  fusiform  cells  of  the  decidua,  accompanied  by  an 
increase  of  the  intercellular  granular  material.  Eventually  the  cells 
undergo  fatty  degeneration,  and  the  whole  structure  becomes  fibroid. 
This  has  generally  been  ascribed  to  inflammatory  changes,  and,  under 
the  name  of  placentitis,  has  been  described  by  many  authors,  and  has 
been  considered  to  be  a  common  disease.  To  it  are  attributed  many 

i  Priestley  :  The  Pathology  of  Intra-uterine  Death,  p.  156. 
«  Whittaker :  Amer.  Journ.  of  Obstet.,  1870-71.  vol.  ill.  p.  229. 
3  Virchow's  Archiv,  1871. 

1G 


242 


PREGNANCY. 


of  the  morbid  alterations  which  are  commonly  observed  in  placentae, 
such  as  hepatizations,  circumscribed  purulent  deposits,  and  adhesions 
to  the  uterine  walls.  Many  modern  pathologists  have  doubted  whether 
these  changes  are  in  any  proper  sense  inflammatory.  Whittaker 
observes  on  this  point :  "  The  disposition  to  reject  placentitis  altogether 
increases  in  modern  times.  Indeed,  it  is  impossible  to  conceive  of  in- 
flammation on  the  modern  theory  (Cohnheim)  of  that  process,  since 
there  are  no  capillaries,  in  the  maternal  portion  at  least,  through  whose 
walls  a  '  migration '  might  occur,  and  there  are  no  nerves  to  regulate 
the  contractility  of  the  vessel-walls  in  the  entire  structure."  Robin 

FIG.  94. 


Double  placenta,  with  single  cord. 


thus  explains  the  various  pathological  changes  above  alluded  to : 
"  What  has  been  taken  for  inflammation  of  the  placenta  is  nothing  else 
than  a  condition  of  transformation  of  blood-clots  at  various  periods. 
What  has  been  regarded  as  pus  is  only  fibrin  in  the  course  of  dis- 
organization, and  in  those  cases  where  true  pus  has  been  found  the  pus 
did  not  come  from  the  placenta,  but  from  an  inflammation  of  the  tissue 
of  the  uterine  vessels  and  an  accidental  deposition  in  the  tissue  of  the 
placenta."  The  extravasations  of  blood  here  alluded  to  are  of  very 
common  occurrence,  and  they  are  found  in  all  parts  of  the  organ  :  in 
its  substance,  on  its  decidual  surface,  or  immediately  below  the  amnion, 
where  they  serve  as  points  of  origin  for  the  cysts  that  are  often  there 
observed.  The  fibrin  thus  deposited  undergoes  retrograde  metamor- 
phosis as  in  other  parts  of  the  body  :  it  becomes  decolorized,  it  under- 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 


243 


goes  fatty  degeneration,  or  becomes  changed  into  calcareous  masses ; 
and  in  this  way,  it  is  supposed,  may  be  explained  the  various  patho- 
logical changes  which  are  so  commonly  observed.  The  amount  of 
retrograde  metamorphosis,  and  the  precise  appearance  presented,  will, 
of  course,  depend  on  the  time  that  has  elapsed  since  the  blood  ex- 
travasations took  place. 

Fatty  degeneration  of  the  placenta,  and  its  influence  on  the 
nutrition  of  the  foetus,  have  been  specially  studied  in  this  country  by 
Barnes  and  Druitt.  Yellowish  masses  of  varying  sizes  are  very  com- 
monly met  with  in  placentae,  and  these  are  found  to  consist,  in  great 
part,  of  molecular  fat,  mixed  with  a  fine  network  of  fibrous  tissue. 

FIG.  95. 


fc  'II 

Fatty  degeneration  of  the  placenta. 

The  true  fatty  degeneration,  however,  specially  affects  the  chorion  villi 
(Fig.  95).  On  microscopic  examination  they  are  found  to  be  altered 
and  misshapen  in  their  contour,  and  to  be  loaded  with  fine  granular 
fat-globules.  Similar  changes  are  observed  in  the  cells  of  the  decidua. 
The  influence  on  the  foetus  will,  of  ccmrse,  depend  on  the  extent  to 
which  the  functions  of  the  villi  are  interfered  with.  The  probable 
cause  of  this  degeneration  is,  no  doubt,  some  obscure  alteration  in 
the  nutrition  of  the  tissue,  depending  on  the  state  of  the  mother's 
health.  The  probability  is  that  generally  the  fatty  degeneration  is 
not  a  primitive  change,  but  a  stage  of  some  other  morbid  condition 
which  precedes  or  is  associated  with  it.  Barnes  believes  that  syphilis 
has  much  influence  in  its  production.  Druitt  has  pointed  out  that 
some  amount  of  fatty  degeneration  is  always  present  in  a  mature 


244 


PREGNANCY. 


FIG.  96. 


placenta,  and  is  probably  connected  with  the  physiological  separation 
of  the  organ  ;  and  Goodell  has  more  recently  suggested  that  an  unusual 
amount  of  this  change  may  be  merely  an  anticipation  of  the  natural 
termination  of  the  life  of  the  placenta.1 

Other  morbid  states  of  the  placenta,  of  greater  rarity,  are  occasion- 
ally met  with,  as  an  oedematous  infiltration  of  its  tissue,  always  occur- 
ring, according  to  Lange,  in  cases  of  hydramnios,  pigmentary  and 
calcareous  deposits,  and  tumors  of  various  kinds ;  but  these  require 
only  a  passing  mention. 

Patholog-y  of  the  Umbilical  Cord. — The  umbilical  cord  may  be 
of  excessive  length,  varying  from  eighteen  to  twenty  inches,  which  is 
its  average  measurement,  up  to  fifty  or  sixty  inches,  and  a  case  is  re- 
corded in  which  it  even  reached  the  extraordinary  length  of  nine  feet. 
If  unusually  long  it  may  be  twisted  round  the  limbs  or  neck  of  the 
child,  and  the  latter  position  may,  in  exceptional  instances,  prove 
injurious  during  labor. 

Some  authors  refer  cases  of  spontaneous  amputation  of  fetal  limbs 
in  utero  to  constrictions  by  the  umbilical  cord,  but  this  accident  is 

more  probably  produced  by  filamentous 
adnexa  of  the  amnion.  Knots  in  the  cord 
are  not  uncommon,  and  they  result  from 
the  foetus,  in  its  movements,  passing 
through  a  loop  of  the  cord  (Fig.  96).  If 
there  is  an  average  amount  of  Wharton's 
jelly  in  the  cord  the  vessels  are  protected 
from  pressure,  and  no  bad  effects  follow. 
G6ry,  in  a  recent  paper  on  the  subject,2 
attempts  to  show  that  such  knots  are  more 
important  than  is  generally  believed,  and 
relates  two  cases  in  which  he  believes  them 
to  have  caused  the  death  of  the  foetus. 

Extreme  torsion  of  the  cord,  an  exag- 
geration of  the  spiral  twists  generally  ob- 
served, may  prove  injurious,  and  even  fatal 
to  the  child  by  obstructing  the  circulation 
in  the  vessels.  Spaeth  mentions  three  cases 
in  which  this  caused  the  death  of  the  foetus, 
the  cord  being  twisted  until  it  was  re- 
duced to  the  thickness  of  a  thread.  Some 
recent  writers,3  hoAvever,  believe  that  ex- 
treme twisting  of  the  cord  is  a  post-mortem  phenomenon  following 
rotation  of  the  foetus  produced,  after  its  death,  by  maternal  movements. 

Anomalies  in  the  distribution  of  the  vessels  of  the  cord  are  of 
common  occurrence.  The  cord  may  be  attached  to  the  edge,  instead 
of  to  the  centre,  of  the  placenta  (battledore  placentci).  It  may  break 
up  into  its  component  parts  before  reaching  the  placenta,  the  vessels 
running  through  the  membranes;  and  if,  in  such  a  case,  traction  on 
the  cord  be  made,  the  separate  vessels  mayjacerate,  and  the  cord 


Knots  of  the  umbilical  cord. 


Amer.  Journ.  of  Obstet.,  1869-70,  vol.  ii.  p.  535. 
L'Union  Medicale,  October,  1876. 
Schauta:  Arch.  f.  Gyn.,  1881,  Bd.  xix.  S.  96. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  245 

become  detached.  There  may  be  two  veins  and  one  artery,  or  only 
one  vein  and  one  artery,  or  there  may  be  two  separate  cords  to  one 
placenta.  These  and  other  anomalies  that  might  be  mentioned  are  of 
little  practical  importance. 

Pathology  of  the  Amnion. — The  principal  pathological  condition 
of  the  amnion  with  which  we  are  acquainted  is  that  which  is  associated 
with  excessive  secretion  of  liquor  amnii,  aoid  is  generally  known  under 
the  name  of  hydramnios,  which  term  Kidd l  limits  to  cases  in  \vhich 
more  than  two  quarts  of  amniotic  fluid  exist.  Its  precise  cause  is  still 
a  matter  of  doubt.  By  some  it  is  referred  to  inflammation  of  the 
amnion  itself;  at  other  times  it  is  apparently  connected  with  some 
morbid  state  of  the  decidua,  which  may  be  found  diseased  and  hyper- 
trophied.  The  foetus  is  very  often  dead  and  shrivelled,  and  the 
placenta  enlarged  and  oedematous.  It  does  not  necessarily  follow, 
however,  that  hydramnios  causes  the  death  of  the  child.  Out  of  thirty- 
three  cases  McClintock  found  that  nine  children  were  born  dead;2  and 
of  the  twenty-four  born  alive,  ten  died  within  a  few  hours,  the  re- 
mainder survived.  There  does  not  appear  to  be  any  marked  relation 
between  the  state  of  the  mother's  health  and  the  occurrence  of  this 
disease ;  and  it  is  certainly  not  necessarily  present  when  the  mother  is 
suffering  from  dropsical  effusions  in  other  parts  of  the  body.  The 
theory  that  the  disease  is  of  purely  local  origin  is  favored  by  the  fact 
that  when  hydramnios  occurs  in  twin  pregnancy  one  ovum  only  is 
generally  affected.  The  probability  is  that  most  cases  of  hydramnios 
are  of  foetal  origin,  and  are  caused  by  some  obstruction  in  the  foetal 
circulation,  mainly  in  the  heart  and  liver,  the  latter  often  syphilitic. 
If  the  maternal  placental  circulation  is  active,  and  the  foetal  impeded, 
compensatory  dropsical  effusion  into  the  sae  of  the  amnion  occurs  as  a 
consequence  of  the  mechanical  obstruction,  and  hydramnios  results. 
Its  effects,  as  regards  the  mother,  are  chiefly  mechanical.  It  rarely 
begins  to  show  itself  before  the  fifth  or  sixth  month  of  pregnancy,  but 
when  once  it  has  commenced  it  rapidly  produces  a  feeling  of  discom- 
fort and  enlargement,  altogether  beyond  that  which  should  exist  at  the 
period  of  pregnancy  which  has  been  reached.  In  advanced  stages  the 
distress  produced  is  often  very  great,  the  enlarged  uterus  pressing  upon 
the  diaphragm,  and  producing  much  embarrassment  of  respiration. 
Premature  expulsion  of  the  foetus  very  often  supervenes.  •  Four  out  of 
McClintock's  patients  died  after  labor,  showing  that  the  maternal 
mortality  is  high — a  result  which  he  refers  to  the  debilitated  state  of 
the  women  who  were  the  subjects  of  the  disease. 

[Hydramnios  is  a  true  cystic  dropsy  of  the  amniotic  sac,  and, 
although  due  to  different  causes,  is  in  the  worst  cases  the  result  of 
obstruction  in  the  placento-fcetal  circuit  of  bloodvessels,  and  mainly 
in  the  liver  or  heart  of  the  foetus.  The  amnion  has  the  anatomical 
features  of  a  secreting  membrane,  and  is  capable  of  endosmosis  and 
exosmosis,  the  latter  of  which  is  notably  exhibited  in  the  removal  of 
liquor  amnii  after  foetal  death  in  an  ectopic  pregnancy.  When  from 

l  "On  the  Diagnosis  of  Dropsy  of  the  Amniou."    Proceedings  of  the  Obstetrical  Society  of 
Dublin,  May  11, 1878. 
*  Diseases  of  Women,  p.  383. 


246  PREGNANCY. 

any  cause  the  circulation  of  blood  is  impeded  in  the  fetus,  and  the 
placenta  still  keeps  up  its  functional  activity,  the  disparity  between 
placental  supply  and  foetal  requirement  will  produce  a  dropsical 
eifusion  as  the  'result  of  the  mechanical  obstruction ;  hence  the  large 
proportion  of  deaths  in  the  foetus  in  cases  of  hydramnios. — ED.] 

Diagnosis. — The  diagnosis  is  not,  as  a  rule,  difficult.  It  has  to  be 
distinguished  from  ascitic  distention  of  the  abdomen,  from  enlargement 
of  the  uterus  from  twin  pregnancy,  and  from  ovarian  tumor,  or  preg- 
nancy complicated  with  ovarian  tumor.  The  first  will  be  recognized 
by  the  superficial  position  of  the  fluid;  the  difficulty  of  feeling  the 
contour  of  the  uterus,  which  is  obscured  by  the  surrounding  fluid,  and 
the  results  of  percussion,  which  show  that  the  fluid  is  free  in  the  peri- 
toneal cavity ;  and  by  the  coexistence  of  dropsical  effusions  in  other 
parts  of  the  body.  The  second  may  be  difficult,  and  even  impossible, 
to  diagnose  from  it:  generally,  however,  in  hydramnios  the  uterine 
tumor  is  more  distinctly  tense  or  fluctuating ;  the  foetal  limbs  cannot 
be  felt  on  palpation ;  and  the  lower  segment  of  the  uterus,  as  felt  per 
vaginam,  is  unusually  distended,  the  presenting  part  not  being  appreci- 
able. Ovarian  tumors,  alone  or  complicating  pregnancy,  may  also  be 
difficult  to  distinguish  from  dropsy  of  the  amnion.  The  general  history 
of  the  case,  and  the  presence  or  absence  of  signs  of  pregnancy,  may 
enable  us  to  arrive  at  a  diagnosis;  and  Kidd  points  out  that  the  posi- 
tion of  the  uterus,  whether  gravid  or  not,  is  usually  low  down  in  the 
pelvis  in  ovarian  dropsy,  while  in  dropsy  of  the  amnion  it  is  drawn 
high  up,  and  reached  with  difficulty  on  vaginal  examination. 

During  labor  an  excessive  amount  of  liquor  amnii  is  often  a  cause 
of  deficient  uterine  action  and  delay,  the  pains  being  feeble  and  in- 
effective. This,  of  course,  tells  chiefly  in  the  first  stage,  which  is  often 
much  prolonged,  unless  the  membranes  are  punctured  early,  and  the 
superabundant  fluid  is  allowed  to  escape. 

Treatment. — No  treatment  is  known  to  have  any  effect  on  the 
disease.  If  the  discomfort  and  distention  are  very  great,  it  may  be 
absolutely  necessary  to  puncture  the  membranes,  and  allow  the  water 
to  escape.  This  inevitably  brings  on  labor.  If  the  pregnancy  be  not 
sufficiently  advanced  to  give  hope  for  the  birth  of  a  living  child,  we 
would  not,  of  course,  resort  to  this  expedient  unless  the  mother's 
health  was  seriously  imperilled.  It  is  possible  that  in  such  cases  the 
patient  might  be  relieved  by  inserting  a  minute  aspirating  needle 
through  the  os,  and  removing  a  certain  quantity  of  the  liquor  amnii 
by  aspiration,  without  inducing  the  labor.  I  have  never  had  an  oppor- 
tunity of  trying  this  expedient,  but  it  seems  a  possibility. 

Deficiency  of  Liquor  Amnii. — A  defective  amount  of  liquor 
amnii  is  said  to  favor  certain  malformations,  by  allowing  the  uterus  to 
compress  the  foetus  unduly.  It  certainly  occasionally  gives  rise  to 
adhesion  between  the  foetus  and  the  membranes,  and  to  the  formation 
of  amniotic  bands  which  are  capable  of  producing  certain  foetal  de- 
formities (pp.  245,  250). 

The  liquor  amuii  itself  varies  much  in  appearance.  It  is  sometimes 
thick  and  treacly,  instead  of  limpid,  and  it  may  be  offensive  in  odor. 
The  cause  of  these  variations  is  not  well  understood. 


PATHOLOGY    OF    THE    DEGIDUA    AND    OVUM.  247 

Pathology  of  the  Foetus. — There  is  abundant  evidence  that  the 
foetus  in  utero  is  subject  to  many  diseases,  some  of  which  cause  its 
death,  and  others  leave  distinct  traces  of  their  existence,  although  not 
proving  fatal.  The  subject  is  of  great  importance,  and  is  Avell  worthy 
of  study.  There  is  still  much  to  be  done  in  this  direction,  which  may 
lead  to  important  practical  results.  I  can,  however,  do  little  more 
than  enumerate  some  of  the  principal  affections  which  have  been 
observed. 

Diseases  Transmitted  through  the  Mother. — It  is  a  well-estab- 
lished fact  that  the  various  eruptive  fevers  from  which  the  mother  may 
suffer  may  be  communicated  to  the  foetus  in  utero.  When  the  mother 
is  attacked  with  confluent  smallpox  she  almost  always  aborts,  but  not 
necessarily  so  when  it  is  discrete  or  modified.  In  such  cases  it  has 
often  happened  that  the  foetus  has  been  born  with  evident  marks  of 
smallpox.  Cases  are  on  record  which  prove  that  the  foetus  was 
attacked  subsequently  to  the  mother.  Thus  a  mother  attacked  with 
smallpox  has  miscarried,  and  has  given  birth  to  a  living  child  showing 
no  trace  of  the  disease,  \vhich,  however,  showed  itself  in  two  or  three 
days;  proving  that  it  had  been  contracted,  and  had  run  through  its 
usual  period  of  incubation,  when  the  foetus  was  still  in  utero.  It  does 
not  follow,  however,  that  the  foetus  is  affected,  as  Serres  has  collected 
twenty-two  cases  in  which  women  suffering  from  smallpox  gave  birth 
to  children  who  had  not  contracted  the  disease.  It  has  been  supposed 
that  in  such  cases  the  child  is  protected  from  smallpox,  though  it  has 
shown  no  symptom  of  having  had  the  disease.  Tarnier,  however, 
cites  two  instances  in  which  such  children  had  smallpox  two  years 
after  birth.  Madge  and  Simpson  record  cases  in  which  vaccination 
performed  on  the  mother  during  pregnancy  protected  the  foetus,  on 
whom  all  subsequent  attempts  at  vaccination  failed.  There  is  evidence 
also  to  prove  that  the  disease  may  be  transmitted  to  the  foetus  through 
a  mother  who  is  herself  unsusceptible  of  contagion;  the  child  having 
been  covered  with  smallpox  eruption,  the  mother  being  quite  free  from 
it.  It  is  probable  that  the  same  facts  which  have  been  observed  with 
regard  to  smallpox  hold  true  with  reference  to  other  zymotic  diseases, 
such  as  scarlet  fever  and  measles,  although  there  is  not  sufficient 
evidence  to  justify  a  positive  assertion  to  that  effect. 

Amongst  other  maternal  diseases,  malaria  and  lead-poisoning  are 
known  to  affect  the  foetus  in  utero.  Dr.  Stokes  relates  cases  in  which 
the  mother  suffered  from  tertian  ague,  the  child  having  also  attacks,  as 
evidenced  by  its  convulsive  movements,  appreciable  by  the  mother, 
which  took  place  at  the  regular  intervals,  but  at  a  different  time  from 
the  mother's  paroxysms.  In  other  cases  the  febrile  paroxysm  comes 
on  at  the  same  time  in  the  foetus  as  in  the  mother;  and  the  fact  has 
been  verified  by  the  observation  that  the  paroxysms  continued  to  recur 
simultaneously  after  delivery.  The  foetus  has  also  been  born  with  dis- 
tinct malarious  enlargement  of  the  spleen.  From  the  frequency  with 
which  largely  hypertrophied  spleens  are  seen  in  mere  infants  in 
malarious  districts,  I  imagine  that  the  intra-uterine  disease  must  be 
common.  I  have  frequently  observed  this  fact  in  India,  although,  of 
course,  without  any  possibility  of  ascertaining  if  the  mothers  had 


248       .  PREGNANCY. 

suffered  from  intermittent  fever  during  pregnancy.  Lead-poisoning  is 
also  known  to  have  a  most  prejudicial  effect  on  the  foetus,  and  fre- 
quently to  lead  to  abortion.  M.  Paul  has  collected  eighty-one  cases1 
in  which  it  caused  the  death  of  the  foetus,  in  some  not  until  after  birth; 
and  occasionally  it  seems  to  have  affected  the  foetus  even  when  the 
mother  escaped. 

Of  all  blood-dyscrasiae  transmitted  to  the  foetus,  the  most  important 
is  syphilis.  Its  influence  in  producing  repeated  abortion  is  elsewhere 
described  (p.  257).  It  may  unquestionably  be  transmitted  to  the  foetus 
without  producing  abortion,  and  at  term  the  mother  may  be  either 
delivered  of  a  living  child,  bearing  evident  traces  of  the  disease ;  of  a 
dead  child  similarly  affected;  or  of  an  apparently  healthy  child  in 
whom  the  disease  develops  after  a  lapse  of  a  month  or  two.  These 
varying  effects  probably  depend  on  the  intensity  of  the  poison  ;  and 
the  longer  the  time  that  has  elapsed  since  the  origin  of  the  disease 
in  the  affected  parent,  the  better  will  be  the  chance  for  the  child.  The 
disease  is,  no  doubt,  generally  transmitted  through  the  mother,  and  if 
she  be  affected  at  the  time  of  conception,  the  infection  of  the  foetus 
seems  certain.  If,  however,  she  contracts  the  disease  at  an  advanced 
period  of  pregnancy,  the  child  may  entirely  escape.  Ricord  even 
believes  that  syphilis  contracted  after  the  sixth  month  of  pregnancy 
never  affects  the  child.  The  father  alone  may  transmit  the  disease  to 
the  ovum ;  and  Hutchinson  has  recorded  cases  to  show  that  the  mother 
may  become  secondarily  affected  through  the  diseased  foetus.  The 
evidences  of  syphilitic  taint  in  a  living  or  dead  child  are  sufficiently 
characteristic.  The  child  is  generally  puny  and  ill-developed.  An 
eruption  of  pemphigus  is  common,  either  fully-developed  bullse,  or 
their  early  stage,  when  they  form  circular  copper-colored  patches. 
This  eruption  is  always  most  marked  on  the  hands  and  feet,  and  a 
child  born  with  such  an  eruption  may  be  certainly  considered  syphi- 
litic. On  post-mortem  examination  the  most  usual  signs  are  small 
patches  of  suppuration  in  the  thymus,  similar  localized  suppurations 
in  the  tissues  of  the  lungs,  indurated  yellowish  patches  in  the  liver, 
and  peritonitis,  the  importance  of  which  in  causing  the  death  of  syphi- 
litic children  has  been  specially  dwelt  on  by  Simpson.2 

The  most  important  of  the  inflammatory  diseases  affecting  the  foetus 
is  peritonitis.  Simpson  has  shown  that  traces  of  it  are  very  frequently 
met  with,  and  that  it  is  not  always  syphilitic.  Sometimes  it  has  been 
observed  when  the  mother  has  been  in  bad  health  during  pregnancy, 
and  at  others  it  seems  to  have  resulted  from  some  morbid  condition 
of  the  foetal  viscera.  Pleurisy  with  effusion  is  another  inflammatory 
affection  which  has  been  noticed. 

The  dropsical  affections  most  generally  met  with  arc  ascites  and 
hydrocephalus,  which  may  both  have  the  effect  of  impeding  delivery. 
Of  these,  hydrocephalus  is  the  more  common,  and  may  give  rise  to 
much  difficulty  in  labor.  Its  causes  are  uncertain,  but  it  probably 
depends  on  some  altered  state  of  the  mother's  health,  as  it  is  apt  to 
recur  in  several  successive  pregnancies,  and  is  not  infrequently  asso- 

i  Arch.  gen.  de  Med.,  1860.  2  Obst.  Works,  vol.  i.  p.  117. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  249 

ciated  -with  an  imperfectly  developed  vertebral  column  and  spiua  bifida. 
The  fluid  collects  in  the  ventricles,  which  it  greatly  distends,  and  these 
then  produce  expansion  and  thinning  of  the  cranium,  the  bones  of 
which  are  widely  separated  from  each  other  at  the  sutures,  which  are 
prominent  and  fluctuating.  In  a  few  cases  internal  hydrocephalus 
may  be  complicated,  and  the  diagnosis  in  labor  consequently  obscured 
by  the  coexistence  of  what  has  been  called  "  external  hydrocephalus." 
This  consists  of  a  collection  of  fluid  between  the  skull  and  the  scalp, 
which  may  be  either  formed  there  originally  or  may  collect  from  a 
rupture  of  one  of  the  sutures  or  fontanelles  during  labor,  through 
which  the  intra-crauial  fluid  escapes. 

Ascites  is  generally  associated  with  hydramnios,  and  sometimes  with 
hydrothorax,  or  other  dropsical  effusions.  It  is  a  rare  affection,  and 
according  to  Depaul1  extreme  distention  of  the  bladder  is  not  un- 
frequeutly  mistaken  for  it. 

Tumors  of  different  kinds  may  be  met  with  in  various  parts  of  the 
child's  body,  which  sometimes  grow  to  a  great  size  and  impede  delivery. 
Tarnier  records  cases  of  meningocele  larger  than  a  child's  head,  and 
large  cystic  growths  have  been  observed  attached  to  the  nates,  pectoral 
region,  or  other  parts  of  the  body.  Cancerous  tumors  of  considerable 
size,  either  external  or  of  the  viscera,  have  also  been  met  with.  Other 
foetal  tumors  may  be  produced  by  congenital  deformities,  such  as  pro- 
jection of  the  liver  or  other  abdominal  viscera  through  a  deficiency  of 
the  abdominal  wall ;  or  spina  bifida  from  imperfectly  developed  verte- 
bra?. The  amount  of  dystocia  produced  by  such  causes  will,  of  course, 
vary  much  in  proportion  to  the  size,  consistency,  and  accessibility  of 
the  tumor. 

"Wounds  and  Injuries  of  the  Foetus. — Accidents  of  serious  gravity 
to  the  foetus  may  happen  from  violence  to  which  the  mother  has  been 
subjected,  such  as  falls  or  blows,  without  necessarily  interfering  with 
gestation.  Many  curious  examples  of  this  kind  are  on  record.  Thus 
a  child  has  been  born  presenting  a  severe  lacerated  wound  extending 
the  whole  length  of  the  spine,  where  both  the  skin  and  the  muscles 
had  been  torn,  and  which  seems  to  have  resulted  from  the  mother 
having  fallen  in  the  last  month  of  pregnancy.  Similar  lacerations  and 
contusions  have  been  observed  in  other  parts  of  the  body,  the  wounds 
being  in  various  stages  of  cicatrization,  corresponding  to  the  lapse  of 
time  since  the  accident  had  occurred.  Intra-uterine  fractures  are  not 
rare,  apparently  arising  from  similar  causes.  In  some  of  these  cases 
the  broken  ends  of  the  bones  had  united,  but,  from  want  of  accurate 
apposition,  at  an  acute  angle,  so  as  to  give  rise  to  much  subsequent 
deformity.  Chaussier  records  two  cases  in  which  there  were  many 
fractures  in  the  same  child — in  one,  one  hundred  and  thirteen,  and  in 
another  forty-two — which  were  in  different  stages  of  repair.  He 
attributes  this  curious  occurrence  to  some  congenital  defect  in  the 
nutrition  of  the  bones,  possibly  allied  to  mollities  ossium.2 

Intra-uterine  amputations  of  foetal  limbs  have  not  unfrequently  been 
observed.  Children  are  occasionally  born  with  one  extremity  more  or 

i  Tarnier's  Cazeaux,  p.  865.  *  Gazette  hebdom.,  1860. 


250 


PREGNANCY. 


FIG.  97. 


Intra-uterine  amputation  of  both 
arms  and  legs. 


less  completely  absent,  and  cases  are  known  in  which  the  whole  four 
extremities  were  wanting  (Fig.  97).  The  mode  in  which  these  mal- 
formations are  produced  has  given  rise  to 
much  discussion.  At  one  time  it  was  sup- 
posed that  the  deficiency  of  the  limb  was  due 
to  gangrene  of  the  extremity,  and  subsequent 
separation  of  the  sphacelated  parts.  Reuss, 
who  has  studied  the  whole  subject  very 
minutely,1  considers  gangrene  in  the  unrup- 
tured  ovum  to  be  an  impossibility,  for  that 
change  cannot  occur  unless  there  is  access  of 
air,  and  when  portions  of  the  separated 
extremity  are  found  in  utero,  as  is  often  the 
case,  they  show  evidences  of  maceration,  but 
not  of  decomposition.  The  general  belief  is 
that  these  intra-uterine  amputations  depend 
on  constriction  of  the  limb  by  folds  or  bands 
of  the  amnion — most  often  met  with  when 
the  liquor  amnii  is  deficient  in  quantity — 
which  obstruct  the  circulation,  and  thus  give 
rise  to  atrophy  of  the  part  below  the  constric- 
tion. It  has  been  supposed  that  the  umbilical 
cord  might,  by  encircling  the  limb,  produce  a  like  result.  It  appears 
doubtful,  however,  whether  this  cause  is  sufficient  to  produce  complete 
separation  of  the  limb,  as  any  great  amount  of  constriction  would 
interfere  with  the  circulation  through  the  cord.  Sometimes,  when 
intra-uterine  amputation  occurs,  the  separated  portion  of  the  limb  is 
found  lying  loose  in  the  amniotio  cavity,  and  is  expelled  after  the 
child.  Cases  of  this  kind  have  been  recorded  by  Martin,  Chaussier, 
and  Watkinson.  More  often  no  trace  of  the  separated  extremity  can 
be  found.  The  explanation  probably  depends  upon  the  period  of  utero- 
gestation  at  which  amputation  took  place.  If  it  occurred  at  a  very 
early  period  of  pregnancy,  before  the  third  month,  the  detached  portion 
would  be  minute  and  soft,  and  would  easily  disappear  by  solution.  If 
at  a  later  period,  this  could  hardly  happen,  and  the  detached  portion 
would  remain  in  utero.  In  cases  of  the  latter  kind  cicatrization  of  the 
stump  has  often  been  observed  to  be  incomplete.  Simpson  pointed  out 
the  occasional  existence  of  rudimentary  fingers  or  toes  on  the  stump  of 
an  amputated  limb,  such  as  are  seen  on  the  thighs  in  Fig.  97.  These 
he  attributed  to  an  abortive  reproduction  of  the  separated  extremity, 
analogous  to  what  is  observed  in  some  of  the  lower  animals.  This 
explanation  has  been  contested  with  much  show  of  reason.  Martin 
believes  that  the  reproduction  is  only  apparent,  and  that  the  rudi- 
mentary extremities  are,  in  reality,  instances  of  arrested  development. 
The  constricting  agents  interfered  with  the  circulation  sufficiently  to 
arrest  the  growth  of  the  limb  below  the  site  of  constriction,  but  not 
sufficiently  to  effect  complete  separation.  If  constriction  occurred  at  a 
very  early  stage  of  development,  an  appearance  similar  to  that  observed 


*  Scanzoni's  Beitrage,  1869. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  251 

by  Simpson  would  be  produced.  It  does  not  follow,  however,  that  all 
cases  of  absence  of  limbs  depend  on  intra-uterine  amputations.  In 
some  cases  they  would  appear  to  be  the  result  of  a  spontaneous  arrest 
of  development,  or  of  congenital  monstrosity.  Mr.  Scott l  relates  a 
case  in  which  a  distinct  hereditary  tendency  was  evident,  and  here  the 
deformity  certainly  could  not  have  resulted  from  the  constriction  of 
aimniotic  bands.  In  this  family  the  grandfather  had  both  forearms 
wanting,  with  rudimentary  fingers  attached ;  the  next  generation 
escaped  ;  but  the  grandchild  had  a  deformity  precisely  similar  to  that 
of  the  grandfather. 

[Arrested  Pullulation. — The  absence  of  a  hand  where  there  are 
rudimentary  evidences  of  an  attempt  to  form  the  thumb  and  fingers 
can  be  accounted  for  much  more  satisfactorily  on  the  theory  of  an 
arrested  development  taking  place  in  the  latter  half  of  the  second 
month  of  embryonic  life  than  upon  the  hypothetical  idea  that  there 
has  boon  first  an  amputation  in  utero,  and  then  an  attempt  of  Nature  to 
reproduce  the  lost  digits  by  a  new  budding  process,  as  taught  by 
Simpson,  and  Annandale.  More  than  thirty  years  ago  I  became  fully 
satisfied  that  there  was  an  inclination  in  Nature  to  repeat  itself  so 
exactly  during  the  pullulative  period  of  embryonic  growth  that  cases  of 
congenital  deficiency  of  the  thumb  and  fingers  of  a  precisely  similar 
character  must  from  time  to  time  present  themselves  to  the  eye  of  the 
medical  observer.  It  so  happened  that  three  such  typical  cases,  all 
exactly  alike,  in  two  boys  and  one  girl,  each  being  strangely  without 
the  left  hand,  came  under  my  notice  during  a  short  perio<J  of  years. 
The  forearm  in  each-  ended  in  a  well-rounded  and  slightly-flattened 
stump,  from  which  protruded  a  row  of  pisiform  nail-less  bodies  repre- 
senting the  embryonic  commencement  of  the  formation  of  a  thumb 
and  four  fingers.  I  saw  these  subjects  at  different  ages  of  infancy  and 
childhood,  and  the  little  pea-like  bodies  remained  the  same,  with  the 
exception  that  they  became  slightly  larger.  In  a  fourth  case,  a  boy, 
the  finger  rudiments  were  entirely  absent,  and  there  was  an  attempt  to 
form  a  thumb,  which  was  useless  and  about  three-quarters  of  an  inch 
long.  The  boy  developed  into  a  powerful  man  of  six  feet.  Cases  of 
the  precise  type  of  the  three  first  named  have  come  under  the  observa- 
tion of  medical  friends. — ED.] 

Death  of  Foetus. — When  from  any  cause  the  foetus  has  died  during 
pregnancy,  it  may  be  either  soon  expelled,  or  it  may  be  retained  in  utero 
for  a  longer  or  shorter  time,  or  even  to  the  full  period.  The  changes 
observed  in  such  foetuses  vary  considerably  according  to  the  age  of  the 
foetus  at  the  time  of  death,  or  the  time  that  it  has  been  retained  in 
utero.  If  it  die  at  an  early  period,  when  the  tissues  are  very  soft,  it 
may  entirely  dissolve  in  the  liquor  amnii,  and  no  trace  of  it  may  be 
found  when  the  membranes  are  expelled.  Or  it  may  shrivel  or  mum- 
mify; and  if  this  happen  in  a  twin  pregnancy,  as  sometimes  occurs, 
the  growing  foetus  may  compress  and  flatten  the  dead  one  against  the 
uterine  wall. 

At  a  later  period  of  pregnancy  a  dead  foetus  undergoes  changes 

1  Obst.  Trans.,  1872,  vol.  xiii.  p.  94. 


252  PREGNANCY. 

ascribed  to  putrefaction,  but  which  produce  appearances  different  from 
those  of  decomposition  in  animal  textures  exposed  to  the  atmosphere. 
There  is  no  offensive  smell,  as  in  ordinary  decay.  The  tissues  are  all 
softened  and  flaccid.  The  more  manifest  changes  are  in  the  skin,  the 
epidermis  of  which  is  separated  from  the  cutis  vera,  which  has  a  deep 
reddish  color.  This  is  especially  apparent  on  the  abdomen,  which  is 
flaccid,  and  hollow  in  the  centre.  The  internal  organs  are  much 
altered.  The  brain  is  diffluent  and  pulpy,  and  the  cranial  bones  loose 
within  the  scalp.  The  structures  of  the  muscles  and  viscera  are  in 
various  stages  of  transformation,  many  having  undergone  fatty  changes, 
and  contain  crystals  of  margarin  and  cholesterin.  The  extent  to  which 
these  changes  occur  depends,  in  a  great  measure,  on  the  length  of  time 
the  foetus  has  been  dead,  but  they  do  not  admit  of  our  estimating  with 
any  degree  of  accuracy  what  that  time  has  been. 

The  symptoms  and  diagnosis  of  the  death  of  the  foetus  may  here 
be  considered.  They  are,  unfortunately,  not  very  reliable.  The  cessa- 
tion of  the  foetal  movements  cannot  be  depended  on,  as  they  are 
frequently  unfelt  for  days  or  weeks,  when  the  child  is  alive  and  well. 
Sometimes  the  death  of  the  foetus  is  preceded  by  its  irregular  and 
tumultuous  movements,  and,  in  women  who  have  been  delivered  of 
several  dead  children  in  succession,  this  sensation  may  guide  us  in  our 
diagnosis.  This  suspicion  may  be  confirmed  by  auscultation.  The 
mere  fact  that  we  are  unable,  at  any  given  time,  to  hear  the  foetal  heart 
will  not  justify  an  opinion  that  the  foetus  is  dead.  If,  however,  the 
foetal  hea/t  has  been  distinctly  heard,  and  after  one  or  two  careful 
examinations,  repeated  at  separate  times,  it  cannot  again  be  made  out, 
the  probability  of  the  child  being  dead  may  be  assumed.  Certain 
changes  in  the  mother's  health  have  been  noted  in  connection  with 
the  death  of  the  foetus,  such  as  depression  and  lowness  of  spirits,  a 
feeling  of  coldness  and  weight  about  the  lower  parts  of  the  abdomen, 
paleness  of  the  face,  a  livid  circle  round  the  eyes,  irregular  shiverings 
and  feverishness,  shrinking  of  the  breasts,  and  diminution  in  the  size 
of  the  abdominal  tumor.  All  these,  however,  are  too  indefinite  to 
justify  a  positive  diagnosis,  and  they  are  not  infrequently  altogether 
absent.  At  most  they  can  do  no  more  than  cause  a  suspicion  as  to 
what  has  happened. 


CHAPTER    X. 

ABORTION  AND  PREMATURE  LABOR. 

Importance  and  Frequency  of  Abortion. — The  premature  ex- 
pulsion of  the  foetus  is  an  event  of  great  frequency.  The  number  of 
foetal  lives  thus  lost  is  enormous.  There  are  few  multiparae  who  have 
not  aborted  at  one  time  or  other  of  their  lives.  Hegar  estimates  that 


ABORTION    AND    PREMATURE    LABOR.  253 

about  one  abortion  occurs  to  every  eight  or  ten  deliveries  at  term. 
Whitehead  has  calculated  that  at  least  90  per  cent,  of  married  women 
who  lived  to  the  change  of  life  had  aborted.  The  influence  of  this 
incident  on  the  future  health  of  the  mother  is  also  of  great  importance. 
It  rarely,  indeed,  proves  directly  fatal,  but  it  often  produces  great 
debility  from  the  profuse  loss  of  blood  accompanying  it ;  and  it  is  one 
of  the  most  prolific  causes  of  uterine  disease  in  after-life,  possibly 
because  women  are  apt  to  be  more  careless  during  convalescence  than 
after  delivery,  and  the  proper  involution  of  the  uterus  is  thus  more 
frequently  interfered  with. 

Definition. — A  not  uncommon  division  of  the  subject  is  into  abortion, 
miscamage,  and  premature  labor,  the  first  name  being  applied  to  expul- 
sion of  the  ovum  before  the  end  of  the  fourth  month  of  utero-gestation  ; 
miscarriage,  to  expulsion  from  the  end  of  the  fourth  to  the  end  of  the 
sixth  month ;  and  premature  labor,  to  expulsion  from  the  end  of  the 
sixth  month  to  the  term  of  pregnancy.  This  is,  however,  a  needless 
and  confusing  subdivision,  which  leads  to  no  practical  result.  It 
suffices  to  apply  the  term  abortion  or  miscarriage  indiscriminately  to 
all  cases  in  wrhich  pregnancy  is  terminated  before  the  foetus  has  arrived 
at  a  viable  age,  and  premature  labor  to  those  in  which  there  is  a  possi- 
bility of  its  survival.  There  is  little  or  no  hope  of  a  foetus  living 
before  the  twenty-eighth  week  or  seventh  lunar  month,  and  this  period 
is  therefore  generally  fixed  on  as  the  limit  between  premature  labor  and 
abortion.  The  rule  is,  however,  not  without  an  occasional,  although 
very  rare,  exception.  Dr.  Keiller,  of  Edinburgh,  has  recorded  an 
instance  in  which  a  foetus  was  born  alive  at  the  fourth  month,  nine 
days  after  the  mother  had  experienced  the  sensation  of  quickening.  I 
myself  recently  attended  a  lady  who  miscarried  in  the  fifth  month  of 
pregnancy,  the  child  being  born  alive,  and  living  for  three  hours. 
Several  cases  are  on  record  in  which  after  delivery  in  the  sixth  month 
the  child  survived  and  was  reared.  The  possibility  of  the  birth  of  a 
living  child  under  such  circumstances  should  be  recognized,  as  it  may 
give  rise  to  legal  questions  of  importance ;  but  the  exceptions  to  the 
ordinary  rule  are  so  rare  that  they  need  not  interfere  with  the  division 
of  the  subject  usually  made. 

Abortion  is  Most  Common  in  Multiparse. — Multiparae  abort  far 
more  frequently  than  primiparae.  This  is  contrary  to  the  statement  in 
many  obstetrical  works.  Thus,  Tyler  Smith  says,  "  there  seems  to  be 
a  greater  danger  of  this  accident  in  the  first  pregnancy."  Schroeder,1 
however,  states  that  twenty-three  multipart  abort  to  three  primiparae ; 
and  Dr.  Whitehead,  of  Manchester,  who  has  particularly  studied  the 
subject,  believes  that  abortion  is  more  apt  to  occur  after  the  third  and 
fourth  pregnancies,  especially  when  these  take  place  toward  the  time 
for  the  cessation  of  menstruation. 

There  can  be  no  doubt  that  women  who  have  aborted  more  than  once 
are  peculiarly  liable  to  a  recurrence  of  the  accident.  This  can  generally 
be  traced  to  the  existence  of  some  predisposing  cause  which  persists 
through  several  pregnancies,  as,  for  example,  a  syphilitic  taint,  a 

i  Schroeder  :  Manual  of  Midwifery,  p.  149. 


254  PREGNANCY. 

uterine  flexion,  or  a  morbid  state  of  the  lining  membrane  of  the  uterus. 
It  is  probable  that  in  many  women  a  recurrence  of  the  accident  induces 
a  habit  of  abortion,  or  perhaps  it  might  be  more  accurate  to  say,  a 
peculiar  irritable  condition  of  the  uterus,  which  renders  the  continuance 
of  pregnancy  a  matter  of  difficulty,  independently  of  any  recognizable 
organic  cause. 

The  frequency  of  abortion  varies  much  at  different  periods  of  preg- 
nancy ;  and  it  occurs  much  more  often  in  the  early  months,  because  of 
the  comparatively  slight  connection  then  existing  between  the  chorion 
and  the  decidua.  At  a  very  early  period  of  pregnancy  the  ovum  is 
cast  off  with  such  facility,  and  is  of  such  minute  size,  that  the  fact  of 
abortion  having  occurred  passes  unrecognized.  Very  many  cases,  in 
which  the  patient  goes  one  or  two  weeks  over  her  time,  and  then  has 
what  is  supposed  to  be  merely  a  more  than  usually  profuse  period,  are 
probably  instances  of  such  early  miscarriages.  Velpeau  detected  an 
ovum,  of  about  fourteen  days,  which  was  not  larger  than  an  ordinary 
pea,  and  it  is  easy  to  understand  how  so  small  a  body  should  pass 
unnoticed  in  the  blood  which  escapes  along  with  it. 

Up  to  the  end  of  the  third  month,  when  miscarriage  occurs,  the  ovum 
is  generally  cast  off  en  masse,  the  decidua  subsequently  coming  away  in 
shreds  or  as  an  entire  membrane.  The  abortion  is  then  comparatively 
easy.  From  the  third  to  the  sixth  month,  after  the  placenta  is  formed, 
the  amnion  is,  as  a  rule,  first  ruptured  by  the  uterine  contractions,  and 
the  foetus  is  expelled  by  itself.  The  placenta  and  membranes  may  then  be 
shed  as  in  ordinary  labor.  It  often  happens,  however,  that  on  account  of 
the  firmness  of  the  placental  adhesion  at  this  period  the  secundines  are 
retained  for  a  greater  or  less  length  of  time.  This  subjects  the  patient 
to  many  risks,  especially  to  those  of  profuse  hemorrhage,  and  of  septi- 
caemia. For  this  reason,  premature  termination  of  the  pregnancy  is 
attended  by  much  greater  danger  to  the  mother  between  the  third  and 
sixth  months  than  at  an  earlier  or  later  date.  After  the  sixth  month 
the  course  of  events  is  not  different  from  that  attending  ordinary  labor. 
The  prognosis  to  the  child  is  more  unfavorable  in  proportion  to  the 
distance  from  the  full  period  of  gestation  at  which  premature  labor 
takes  place. 

Causes. — The  causes  of  abortion  may  conveniently  be  subdivided 
into  the  predisposing  and  exciting,  the  latter  being  often  slight,  and  such 
as  would  have  no  effect  in  inducing  uterine  contractions  in  women 
unless  associated  with  one  or  more  of  the  former  class  of  causes.  The 
predisposition  to  abortion  may  depend  on  some  condition  interfering 
with  the  vitality  of  the  ovum,  or  its  relation  to  the  maternal  structures, 
or  on  certain  conditions  directly  affecting  the  mother's  health. 

One  of  the  most  common  antecedents  of  abortion  is  the  death  of  the 
foetus,  which  leads  to  secondary  changes,  and  ultimately,  produces  the 
uterine  contractions  which  end  in  its  expulsion.  The  precise  causes  of 
death  in  any  given  case  cannot  always  be  accurately  ascertained,  as 
they  sometimes  depend  on  conditions  which  are  traceable  to  the 
maternal  structures,  at  others  to  the  ovular,  or,  it  may  be,  to  a  combina- 
tion of  the  two.  Nor  does  it  by  any  means  follow  that  the  death  of  the 
ovum  immediately  results  in  its  expulsion.  The  mode  in  which  death 


ABORTION    AXD    PREMATURE    LABOR.  255 

of  the  ovum  produces  abortion  is  not  difficult  to  understand,  for  it 
necessarily  leads  to  changes  in  the  relations  between  the  ovular  and 
maternal  structures ;  these  changes  cause  hemorrhages — partly  external 
and  partly  into  the  membranes — which,  in  their  turn,  excite  uterine 
contraction.  Extravasations  of  blood  may  take  place  in  various  posi- 
tions. One  of  the  most  common  is  into  the  decidual  cavity,  between 
the  decidua  vera  and  the  decidua  reflexa,  or  between  the  decidua  vera 
and  the  uterine  walls.  If  the  hemorrhage  is  only  slight,  and  especially 
if  it  conies  from  that  portion  of  the  decidua  near  the  internal  os,  and 
at  a  distance  from  the  ovum,  there  need  be  no  material  separation,  and 
pregnancy  may  continue.  This  explains  the  cases  occasionally  met 
with  in  which  there  is  more  or  less  hemorrhage,  without  subsequent 
abortion.  When  the  amount  of  extravasated  blood  is  at  all  great, 

FIG.  98. 


An  apoplectic  ovum,  with  blood  efiused  in  masses  under  the  foetal  surface 
of  the  membranes. 

separation  and  abortion  necessarily  result,  and  the  decidua  will  be 
found  on  expulsion  to  have  coagula  on  its  surface,  and  between  its 
various  layers  which  are  found  to  project  into  the  cavity  of  the  amnion 
(Fig.  98).  In  other  cases  hemorrhage  is  still  more  extensive,  and,  after 
breaking  through  the  decidua  reflexa,  it  forms  clots  between  it  and  the 
chorion,  and  even  in  the  cavity  of  the  amnion.  Supposing  expulsion 
to  take  place  shortly  after  coagula  are  deposited  among  the  membranes, 
the  blood  is  little  altered,  and  we  have  an  ordinary  abortion.  If,  how- 
ever, the  ovum  is  retained,  the  coagulated  fibrin  and  the  placenta  or 
membranes  undergo  secondary  changes  which  lead  to  the  formation  of 
moles.  The  so-called  fleshy  mole  (Fig.  99)  is  often  retained  for  many 
weeks  or  months  after  the  death  of  the  foetus,  and  during  this  time 
there  may  be  but  little  modification  of  the  usual  symptoms  of  preg- 


256 


PREGNANCY. 


nancy ;  or,  as  is  frequently  the  case,  it  gives  rise  to  occasional  hemor- 
rhage, until  at  last  uterine  contractions  come  on,  and  it  is  cast  off  in 
the  form  of  a  thick  fleshy  mass  having  but  little  resemblance  to  the 
ordinary  products  of  conception.  The  most  probable  explanation  of 
its  formation  is  that  when  hemorrhage  originally  took  place  the 
effusion  of  blood  was  not  sufficient  to  effect  the  entire  separation  and 
expulsion  of  the  ovum.  Part  of  the  membranes  or  of  the  placenta — 
if  that  organ  had  commenced  to  form — retained  its  organic  connection 
with  the  uterus,  while  the  foetus  perished.  The  attached  portion  of 
the  placenta  or  membranes  continues  to  be  nourished,  although  abnor- 
mally. The  foetus  generally  entirely  disappears,  especially  if  it  has 
perished  at  an  early  period  of  utero-gestation,  when  it  becomes  dissolved 
in  the  liquor  amnii :  or  it  may  become  macerated,  shrivelled,  and 


FIG.  99. 


Blighted  ovum,  with  fleshy  degeneration  of  the  membranes. 


greatly  altered  in  appearance.  The  effused  blood  becomes  decolorized 
from  the  absorption  of  the  corpuscles ;  and,  according  to  Scanzoni, 
fresh  vessels  are  developed  in  the  fibrin,  which  increase  the  vascular 
attachment  of  the  mole  to  the  uterine  walls.  The  placenta  and  mem- 
branes may  go  on  increasing  in  thickness  until  they  form  a  mass  of 
considerable  size.  Careful  microscopic  examination  will  almost  always 
enable  us  to  discover  the  villi  of  the  chorion,  altered  in  appearance,  often 
loaded  with  granular  fattv  molecules,  but  sufficiently  distinct  to  be 
readily  recognizable. 

Important  as  are  the  causes  of  abortion  arising  from  some  morbid 
condition  of  the  ovum,  they  are  not  more  so  than  those  which  depend 
on  the  maternal  state ;  and  it  is  to  be  observed  that  the  former  are  often 
indirect  causes  produced  by  primary  maternal  changes.  Many  of  these 
maternal  causes  act  by  producing  hyperseinia  of  the  uterus,  which  leads 
to  extravasation  of  blood.  Thus  abortion  is  aut  to  occur  in  women  who 


ABORTION    AND    PREMATURE    LABOR.  257 

lead  unhealthy  lives,  such  as  those  who  occupy  overheated  and  ill- 
ventilated  rooms,  or  indulge  to  excess  in  the  fatigues  and  pleasures  of 
society,  in  the  use  of  alcoholic  drinks,  and  the  like.  Over-frequent 
coitus  has  been,  for  the  same  reason,  observed  to  produce  a  remarkable 
tendency  to  abortion,  and  Parent-Duchatelet  has  noted  that  it  is  of 
very  frequent  occurrence  amongst  women  of  loose  life.  Many  diseases 
strongly  predispose  to  it,  such  as  fevers,  zymotic  diseases  of  all  kinds, 
measles,  scarlet  fever,  smallpox,  and  diseases  of  the  respiratory  organs, 
such  as  bronchitis  and  pneumonia.  Syphilis  is  well  known  to  be  one 
of  the  most  frequent  causes,  and  one  that  is  likely  to  act  in  successive 
pregnancies.  It  may  act  so  that  the  pregnancy  is  brought  to  a  pre- 
mature termination,  time  after  time,  until  the  constitutional  disease  is 
eradicated  by  appropriate  treatment.  It  acts  in  some  cases  through 
the  influence  of  the  father  in  producing  a  diseased  ovum ;  and  it  is  the 
only  cause  which  can  with  certainty  be  traced  to  the  state  of  the  father's 
health.  Many  other  morbid  conditions  of  the  blood  also  dispose  to 
abortion.  It  has  been  observed  to  be  a  frequent  result  of  lead -poisoning, 
also  of  the  presence  of  noxious  gases  in  the  atmosphere,  such  as  an 
excess  of  carbonic  acid. 

Many  causes  act  through  the  nervous  system,  such  as  fright,  anxiety, 
sudden  shock,  and  the  like.  Thus  there  are  numerous  instances  on 
record  in  which  women  aborted  suddenly  after  the  receipt  of  some  bad 
news,  and  it  is  said  to  have  been  of  frequent  occurrence  in  women  im- 
mediately before  execution.  The  influence  of  irritation  propagated 
through  the  nervous  system  from  a  distance,  tending  to  produce  uterine 
contraction  and  abortion  through  the  agency  of  reflex  action,  has  been 
specially  dwelt  upon  by  Tyler  Smith.  Thus  he  points  out  that  abortion 
not  unfrequently  occurs  from  the  irritation  of  constant  suckling  in 
women  who  become  pregnant  during  lactation.  The  effect  of  suckling 
in  producing  uterine  contraction  is,  indeed,  well  known,  and  the  appli- 
cation of  the  child  to  the  breast  for  this  purpose  has  long  been  recog- 
nized as  a  method  of  treatment  in  post-partum  hemorrhage.  The 
irritation  of  the  trifacial  in  severe  toothache ;  of  the  renal  nerves  in 
cases  of  gravel,  in  albuminuria,  etc. ;  of  the  intestinal  nerves  in  exces- 
sive vomiting,  in  diarrhcea,  obstinate  constipation,  ascarides,  etc.,  all 
act  in  the  same  way.  We  may,  perhaps,  also  explain  by  this  hypoth- 
esis the  fact  that  women  are  more  apt  to  abort  at  what  would  have 
been  the  menstrual  epoch  than  at  other  times,  as  the  ovarian  nerves 
may  then  be  subject  to  undue  excitement.  It  is  probable,  however, 
that  there  may  be  also  at  these  times  more  or  less  active  congestion  of 
the  decidua,  which  may  predispose  to  laceration  of  its  capillaries  and 
blood  extravasation.  Such  congestion  exists  in  those  exceptional  cases 
in  which  menstruation  continues  for  one  or  more  periods  after  concep- 
tion, the  blood  probably  escaping  from  the  space  between  the  decidua 
vera  and  reflexa ;  and,  therefore,  there  is  no  reason  to  question  its  also 
happening  even  when  such  abnormal  menstruation  is  not  present. 

Certain  physical  causes  may  produce  abortion  by  separating  the 
ovum.  Thus  it  may  follow  a  fall,  a  blow,  or  other  accidents  of  a 
trivial  character.  On  the  other  hand,  women  may  be  subjected  to 
injuries  of  the  severest  kind  without  aborting.  The  probability,  there- 

17 


258  PREGNANCY. 

fore,  is  that  these  apparently  trivial  causes  only  operate  in  women  who, 
for  some  other  reason,  are  predisposed  to  the  accident.  This  is  borne 
out  by  the  fact — which  is  well  known  in  these  days,  when  the  artificial 
production  of  abortion  is,  unhappily,  far  from  a  very  rare  event — that 
it  is  by  no  means  easy  to  destroy  the  vitality  of  the  fetus.  I  myself 
know  of  a  case  in  which  the  uterine  sound  was  passed  several  times 
into  a  pregnant  uterus  without  producing  abortion,  the  pregnancy  pro- 
ceeding to  term.  Oldham  has  related  a  similar  case  in  which  he  in 
vain  attempted  to  induce  abortion  by  the  sound  in  a  case  of  contracted 
pelvis;  and  Duncan  has  mentioned  an  instance  in  which  an  intra- 
uteriue  stem  pessary  was  unwittingly  introduced  and  worn  for  some 
time  by  a  pregnant  woman  without  any  bad  effect.  The  fact  that 
pregnancy  is  with  difficulty  interfered  with  when  there  is  a  healthy 
relation  between  the  ovum  and  the  uterus,  no  doubt  explains  the 
disastrous  effects  of  criminal  abortion,  which  have  been  especially 
insisted  on  by  many  of  our  American  brethren. 

Morbid  states  of  the  uterus  have  an  important  influence  in  the  pro- 
duction of  abortion.  Any  condition  which  mechanically  interferes 
with  the  proper  development  of  the  uterus  is  apt  to  operate  in  this 
way.  Amongst  these  may  be  mentioned  fibroid  tumors  ;  the  presence 
of  old  peritoneal  adhesions,  rendering  the  womb  a  more  or  less  fixed 
organ  ;  but,  above  all,  flexion  and  displacement  of  the  uterus.  Eetro- 
flexion  of  the  uterus  is,  unquestionably,  one  of  the  most  frequent 
factors  in  its  production,  not  only  on  account  of  the  irritation  which 
the  abnormal  position  sets  up,  but  from  interference  with  the  uterine 
circulation,  which  leads  to  the  effusion  of  blood  and  the  death  of  the 
ovum.  An  inflamed  condition  of  the  cervical  and  uterine  mucous 
membranes  will  act  in  the  same  way  should  pregnancy  have  occurred, 
although  such  a  condition  more  often  prevents  conception  taking  place. 

Symptoms. — One  of  the  earliest  indications  of  impending  abortion  is 
more  or  less  hemorrhage.  This  may  at  first  be  slight,  and  may  last  for  a 
short  time  only,  recurring  after  an  interval  of  time,  or  it  may  commence 
with  a  sudden  and  profuse  discharge.  Occasionally  it  is  very  abundant, 
and  its  continuance  and  amount  form  one  of  the  gravest  symptoms  of 
the  accident.  After  the  loss  of  blood  has  continued  for  a  greater  or 
less  length  of  time — it  may  be  even  for  some  days — uterine  contrac- 
tions come  on,  recurring  at  regular  intervals,  and  eventually  lead  to 
the  expulsion  of  the  ovum.  More  rarely  the  impending  miscarriage 
commences  with  pains,  which  lead  to  laceration  of  vessels  and  hemor- 
rhage. 

As  long  as  one  or  other  of  these  symptoms  exist  alone,  we  may 
hope  to  avert  the  threatened  miscarriage ;  but  when  both  occur  together 
there  is  little  or  no  chance  of  its  being  arrested.  Certain  premonitory 
symptoms  are  described  by  authors  as  common  in  abortion,  such  as 
feverishness,  shivering,  a  sensation  of  coldness;  all  of  which  are 
obscure  and  unreliable,  and  are  certainly  much  more  frequently  absent 
than  present. 

If  the  pregnancy  be  early  it  is  probable  that  the  entire  ovum  will 
be  shed  with  little  trouble,  and  it  often  passes  unperceived  in  the  clots 
which  surround  it.  It  is,  therefore,  of  importance  that  all  the  dis- 


ABORTION    AND    PREMATURE    LABOR.  259 

charges  should  be  very  carefully  examined.  After  the  second  month 
the  rigid  and  undilated  cervix  presents  a  formidable  obstacle  to  the 
escape  of  the  ovum,  and  it  may  be  a  considerable  time  before  there  is 
sufficient  dilatation  to  admit  of  its  passage.  This  is  gradually  effected 
by  the  continuance  of  pains,  but  not  "without  a  severe  loss  of  blood. 
It  may  be  that  the  amuion  is  ruptured  and  the  foetus  expelled  first. 
After  a  lapse  of  time  the  secuudines  are  also  shed,  but  there  may  be  a 
considerable  delay,  amounting  even  to  days,  before  this  is  effected. 
As  long  as  any  portions  of  the  membranes  are  retained  in  utero,  the 
patient  is  necessarily  subjected  to  considerable  risk,  not  only  from  the 
continuance  of  hemorrhage,  but  also  from  septicaemia.  Hence  it  may 
be  laid  down  as  a  rule  that  we  can  never  consider  our  patient  out  of 
danger  until  we  have  satisfied  ourselves  that  the  whole  of  the  uterine 
contents  have  been  expelled. 

Treatment. — Our  first  endeavor  in  any  case  of  impending  miscar- 
riage will  be,  of  course,  to  avert  the  threatened  accident,,  If  hemor- 
rhage has  not  been  excessive,  and  if,  on  vaginal  examination — which 
should  always  be  practised — we  find  no  dilatation  of  the  os,  we  may 
entertain  a  reasonable  hope  of  success.  If,  on  the  contrary,  we  find 
the  os  beginning  to  open,  if  we  are  able  to  insert  the  finger  through  it 
so  as  to  touch  the  ovum,  especially  if  pains  also  exist,  we  are  justified 
in  considering  abortion  to  be  inevitable,  and  the  indication  will  then 
be  to  have  the  ovum  expelled,  and  the  case  terminated  as  soon  as  pos- 
sible. In  the  former  case  the  most  absolute  rest  is  the  first  thing  to 
insist  on.  The  patient  should  be  placed  in  bed,  not  overburdened 
with  clothes,  in  a  cool  temperature,  and  she  should  have  a  light  and 
easily  assimilated  diet.  All  movements,  even  rising  out  of  bed  to 
empty  the  bladder  or  bowels,  should  be  absolutely  prohibited.  To 
avert  the  tendency  to  the  commencement  of  uterine  contraction  there 
is  no  remedy  so  useful  as  opium,  which  must  be  given  freely  and  fre- 
quently repeated.  It  may  be  administered  either  in  the  form  of 
laudanum  or  of  Battley's  sedative  solution,  which  has  the  advantage 
of  producing  less  general  disturbance.  It  may  be  advantageously 
exhibited  in  doses  of  from  twenty  to  thirty  minims,  and  repeated  after 
a  few  hours.  A  still  better  preparation  is  chlorodyne,  which  I  have 
found  of  extreme  value  in  arresting  impending  miscarriage,  in  doses  of 
ten  minim/?,  repeated  every  third  or  fourth  hour.  If  from  any  other 
cause  it  is  considered  inadvisable  to  give  the  sedative  by  the  mouth, 
it  may  be  administered  in  a  small  starch  enema  per  rectum.  In  all 
cases  it  will  be  necessary  to  keep  the  patient  more  or  less  under  the 
influence  of  the  drug  for  several  days,  and  until  all  symptoms  of  mis- 
carriage have  passed  away.  Care  should  be  taken  that  the  bowels  do 
not  become  locked  up  by  the  action  of  the  opiates — as  this  might  of 
itself  be  a  cause  of  irritation — and  their  constipating  effects  ought  to 
be  obviated  by  small  doses  of  castor  oil,  or  other  gentle  aperient. 
Various  subsidiary  methods  of  treatment  have  been  recommended,  such 
as  bleeding  from  the  arm,  or  the  local  application  of  leeches  in  sup- 
posed plethoric  states  of  the  system  ;  revulsives,  such  as  dry  cupping  to 
the  loins ;  the  application  of  ice,  to  check  hemorrhage ;  astringents,  such 
as  acetate  of  lead  or  gallic  acid,  for  the  same  purpose.  Most  of  these, 


260  PREGNANCY. 

if  not  hurtful,  will  be  at  least  useless.  The  cases  iu  which  venesection 
would  be  beneficial  are  extremely  rare,  and  the  local  applications,  espe- 
cially cold,  are  much  more  apt  to  favor  than  to  prevent  uterine  action. 

In  cases  of  repeated  miscarriage  in  successive  pregnancies,  a  special 
course  of  prophylactic  treatment  is  indicated,  and  is  often  attended 
with  much  success.  In  cases  of  this  kind  the  first  indication,  and  one 
which  ought  to  be  carefully  attended  to,  is  to  seek  for,  and,  if  possible, 
to  remove  or  mitigate  the  cause  which  has  given  rise  to  the  former 
abortions.  Those  causes  which  depend  on  constitutional  states  must 
first  be  carefully  investigated,  and  treated  according  to  the  indications 
present.  These  may  be  obscure  and  not  easily  discovered ;  but  it  is 
certainly  unwise  to  assume  too  readily  the  existence  of  what  has  been 
called  "  a  habit  of  abortion,"  which  further  inquiry  may  prove  to  be 
only  an  indication  of  constitutional  debility,  degeneracy  of  the  placental 
structures,  or  a  latent  and  unsuspected  syphilitic  taint.  If  constitu- 
tional debility  be  present  to  a  marked  extent,  a  generous  diet  and  a 
restorative  course  of  treatment  (preparations  of  iron,  quinine,  and  other 
suitable  tonics)  may  effect  the  desired  object. 

Local  congestion  of  the  uterus  or  a  general  plethoric  state  of  the 
patient  have  often  been  supposed  to  be  efficient  causes  of  recurring 
abortion.  Dr.  Henry  Bennet  has  especially  dwelt  on  the  influence  of 
congestion  and  abrasions  of  the  cervix  in  causing  premature  expulsion 
of  the  foetus,1  and  recommends  the  topical  application  of  nitrate  of 
silver  or  other  caustics  to  the  inflammatory  abrasions  existing  on  the 
neck  of  the  womb.  Formerly  venesection  was  a  favorite  remedy  ;  and 
many  authors  have  recommended  the  local  abstraction  of  blood  by 
leeches  applied  to  the  groin,  or  around  the  anus,  or  even  to  the  cervix. 
The  influence  of  general  plethora  is  more  than  doubtful ;  and  although 
local  congestions  are,  probably,  much  more  effective  causes,  still  it  would 
seem  more  judicious  to  treat  them  by  rest  and  local  sedatives  rather 
than  by  topical  applications,  which,  injudiciously  applied,  might  pro- 
duce the  very  accident  they  were  intended  to  prevent. 

The  position  of  the  uterus  should  be  carefully  investigated.  If  it 
be  found  to  be  retroflexed,  a  well-fitting  Hodge's  pessary  should  be 
applied,  so  as  to  support  it  until  it  has  completely  risen  out  of  the 
pelvis. 

The  possibility  of  syphilitic  infection  should  always  be  inquired 
into,  for  this  poison  may  act  on  the  product  of  conception  long  after 
all  appreciable  traces  of  it  have  disappeared  from  the  infected  parent. 
Should  there  be  recurrent  abortions  in  a  patient  who  had  formerly 
suffered  from  syphilis,  or  whose  husband  had  at  any  time  contracted 
the  disease,  no  time  should  be  lost  in  using  appropriate  anti-syphilitic 
remedies,  which  should  invariably  be  administered  both  to  the  husband 
and  wife.  Diday  especially  insists  that  in  such  cases  it  is  not  sufficient 
to  submit  the  father  and  mother  to  a  mercurial  course  in  the  absence 
of  pregnancy,  but  that,  as  each  successive  impregnation  occurs,  the 
mother  should  again  commence  anti-syphilitic  treatment,  even  though 
she  has  no  visible  traces  of  the  disease.2  In  this  way  there  is  reason- 

1  On  Inflammation  of  the  Uterus,  p.  432. 

*  Diday,  Infantile  Syphilis,  Sjd.  Soc.  Trans.,  p.  207. 


ABORTION    AND    PREMATURE    LABOR.  261 

able  ground  for  hoping  that  infection  of  the  ovum  may  be  prevented. 
I  think,  too,  that  we  may  be  the  more  encouraged  to  persevere  in  the 
treatment  of  these  unfortunate  cases,  from  the  fact  that  the  syphilitic 
poison  tends  to  wear  itself  out.  I  have  seen  several  cases  in  which 
this  taint  at  first  produced  early  abortion,  then  each  successive  preg- 
nancy was  of  longer  duration,  until  eventually  a  living  child  was  born. 

In  fatty  degeneration  of  the  chorion  villi,  and  in  other  morbid  states 
of  the  placenta,  which  act  by  preventing  the  proper  nutrition  of  the 
foetus  and  the  due  aeration  of  its  blood,  there  is  no  reliable  means  of 
treatment  except  the  general  improvement  of  the  mother's  health. 
Simpson  strongly  recommended  the  administration  of  chlorate  of  potash 
in  cases  in  which  the  child  habitually  dies  in  the  later  months  of  preg- 
nancy, on  the  supposition  that  it  supplied  to  the  blood  a  large  amount 
of  oxygen,  and  thus  made  up  for  any  deficiency  in  the  supply  of  that 
element  through  the  placental  tufts.  The  theory  is,  at  best,  a  doubtful 
one,  although  I  believe  the  drug  to  be  unquestionably  beneficial  in 
<^ases  of  the  kind.  It  probably  acts  by  its  tonic  properties  rather  than 
in  the  manner  Simpson  supposed.  It  may  be  given  in  doses  of  fifteen 
to  twenty  grains  three  times  a  day,  and  may  be  advantageously  com- 
bined with  small  doses  of  dilute  hydrochloric  acid.  In  frequently 
recurring  premature  labors  with  dead  children,  Simpson  strongly 
recommended  the  induction  of  premature  labor  a  little  before  the  time 
at  which  we  had  reason  to  believe  that  the  foetus  had  usually  perished ; 
or,  in  other  words,  before  the  placental  disease  had  advanced  sufficiently 
far  to  interfere  with  its  nutrition.  The  practice  has  constantly  been 
adopted  with  success,  and  is  perfectly  legitimate,  but  the  difficulty,  of 
course,  is  to  fix  on  the  right  time.  Careful  auscultation  of  the  foetal 
heart  may  be  of  some  use  in  guiding  us  to  a  decision,  as  the  death  of 
the  foetus  is  generally  preceded  for  some  days  by  irregular,  tumultuous, 
and  intermittent  action  of  the  heart. 

There  will  always  remain  a  certain  number  of  cases  in  which  no 
appreciable  cause  can  be  discovered.  Under  such  circumstances  pro- 
longed rest,  at  least  until  the  time  has  passed  at  which  abortion 
formerly  took  place,  will  afford  the  best  chance  of  avoiding  a  recur- 
rence of  the  accident.  There  must  always  be  some  difficulty  in  carry- 
ing out  this  indication,  inasmuch  as  the  patient's  health  is  apt  to  suffer 
in  other  ways  from  the  confinement,  and  the  want  of  fresh  air  and 
exercise  which  it  entails.  The  strictness  with  which  rest  should  be 
insisted  on  must  vary  in  different  cases,  but  it  should  be  specially 
attended  to  at  what  would  have  been  the  menstrual  periods.  At  these 
times  the  patient  should  remain  in  bed  altogether ;  at  others  she  may 
lie  on  a  sofa,  and,  if  circumstances  permit,  spend  part  of  the  day  at 
least  in  the  open  air.  Sexual  intercourse  should  be  prohibited. 
Should  actual  symptoms  of  abortion  come  on,  the  preventive  treat- 
ment, already  indicated,  may  be  resorted  to.  Great  care,  however, 
should  be  used  in  prescribing  opiates  as  preventives,  and  they  should 
be  given  for  a  specified  time  only.  I  have  seen,  more  than  once,  an 
incurable  habit  of  opium-eating  originate  from  the  incautious  and  too 
long-continued  exhibition  of  the  drug  in  such  cases. 

When  we  have  satisfied  ourselves  that  abortion   is  inevitable,  we 


262  PREGNANCY. 

must  proceed  to  employ  treatment  that  favors  the  expulsion  of  the 
ovum. 

If  the  os  be  sufficiently  dilated,  and  the  pains  strong,  we  may  find 
the  ovum  separated  and  protruding  from  the  os.  We  may  then  be 
able  to  detach  it  by  the  finger.  For  this  purpose  the  uterus  is  de- 
pressed from  without  by  the  left  hand,  while  an  endeavor  is  made  to 
scoop  out  the  ovum  with  the  examining  finger.  If  it  be  out  of  reach 
and  yet  appear  detached,  chloroform  should  be  administered,  the 
whole  hand  introduced  into  the  vagina,  and  the  finger  into  the  uterine 
cavity.  The  complete  detachment  of  the  ovum  can,  in  this  way,  be 
far  more  readily  and  safely  effected  than  by  using  any  of  the  many 
ovum  forceps  which  have  been  invented  for  the  purpose. 

If  the  ovum  be  not  sufficiently  separated  or  the  os  be  undilated, 
means  must  be  taken  to  control  the  hemorrhage  until  the  former  can 
be  removed  or  expelled.  It  is  here  that  plugging  of  the  vagina  finds 
its  most  useful  application.  This  may  be  done  in  various  ways.  That 
most  usually  employed  is  filling  the  vagina  with  a  tolerably  large 
sponge,  in  the  interstices  of  which  the  blood  coagulates.  A  better 
plan  is  to  soak  a  number  of  pledgets  of  cotton-wool  in  carbolized  water 
and  tie  a  string  around  each.  The  vagina  can  be  completely  and 
effectively  packed  with  these  ;  and  this  is  best  done  through  a  speculum, 
or,  better  still,  with  the  aid  of  a  duck-bill  speculum,  the  patient  being 
placed  on  her  left  side.  Each  pledget  should  be  covered  with  glycerin, 
which  completely  prevents  the  offensive  odor  which  otherwise  always 
arises.  The  pledgets  can  be  removed  by  traction  on  the  strings,  but  if 
these  are  not  used  much  pain  is  caused  in  getting  them  out  of  the  vagina. 
The  plug  should  never  be  left  in  for  more  than  six  or  eight  hours,  after 
which  a  fresh  one  may  be  inserted  if  necessary.  Two  or  three  full 
doses  of  the  liquid  extract  of  ergot,  of  half  an  ounce  to  an  ounce  each, 
or  a  subcutaneous  injection  of  ergotine,  may  be  given  while  the  plug  is 
in  position.  The  plug  itself  is  a  strong  excitant  of  uterine  action,  and 
the  two  combined  often  effect  complete  detachment,  so  that,  on  the 
removal  of  the  tampon,  the  ovum  may  be  found  lying  loose  in  the  os 
uteri.  If  the  os  be  undilated  and  the  ovum  entirely  out  of  reach,  the 
former  may  be  opened  by  means  of  sponge  or  laminaria  tents,  or  by 
Hegar's  dilators.  I  think  a  well-prepared  sponge  tent  the  most 
effectual,  and  it  can  be  maintained  in  situ  by  a  vaginal  plug  below  it. 
It  also  acts  as  a  most  efficient  plug,  effectually  controlling  all  hemor- 
rhage. In  a  few  hours  it  opens  up  the  os  sufficiently  to  admit  the 
finger. 

The  most  troublesome  cases  are  those  in  which,  the  fetus  is  first 
expelled,  and  the  placenta  and  membranes  remain  in  utero.  As  long 
as  this  is  the  case  the  patient  can  never  be  considered  safe  from  the 
occurrence  of  septicaemia.  Dr.  Priestley  has  strongly  insisted  on  the 
importance  of  removing  the  secundines  as  soon  as  possible.  There 
can  be  no  doubt  that  this  should  be  done  whenever  it  is  feasible. 
Cases,  however,  are  frequently  met  with  in  which  any  forcible  attempt 
at  removal  would  be  likely  to  prove  very  hurtful,  and  in  which  it  is 
better  practice  to  control  hemorrhage  by  the  plug  or  sponge  tent,  and 
wait  until  the  placenta  is  detached,  which  it  will  generally  be  in  a 


ABORTION    AND    PREMATURE    LABOR.  263 

day  or  two  at  most.  Under  such  circumstances  foetor  and  decomposi- 
tion of  the  secundines  may  be  prevented  by  intra-uterine  antiseptic 
injections.  Provided  the  os  be  sufficiently  patulous  to  prevent  the 
collection  of  the  fluid  in  the  uterine  cavity,  and  not  more  than  a 
drachm  or  two  of  fluid  be  injected  at  a  time,  so  as  simply  to  wash  away 
and  disinfect  decomposing  detritus,  they  can  be  used  with  perfect 
safety.  Sometimes  cases  are  met  with  in  which  the  os  has  entirely 
closed,  and  in  which  we  can  only  suspect  the  retention  of  the  placenta 
by  the  history  of  the  case,  the  continuance  of  hemorrhage,  or  the 
presence  of  a  foetid  discharge.  Should  we  see  reason  to  suspect  this, 
the  os  must  be  dilated  and  the  uterine  cavity  thoroughly  explored 
under  chloroform.  This  condition  of  things  is  far  from  uncommon 
in  women  who  have  not  had  medical  assistance  from  the  first,  and  it 
often  gives  rise  to  very  troublesome  and  anxious  symptoms.  It  has 
been  said  that  placentae  thus  retained  have  been  completely  absorbed,  and 
cases  of  the  kind  have  been  related  by  Naegele  and  Osiander.  The 
spontaneous  absorption,  however,  of  so  highly  organized  a  body  as  the 
placenta  would  be  a  phenomenon  of  the  most  remarkable  character ; 
and  it  seems  more  natural  to  suppose  that,  in  most  cases  of  the  kind, 
the  placenta  has  been  cast  oif  without  the  knowledge  of  the  patient. 
Sometimes  the  placenta  never  becomes  entirely  detached,  and,  retaining 
organic  connection  with  the  uterine  walls,  forms  what  has  been  called  a 
" placenta!  polypus.  This  may  produce  secondary  hemorrhages,  in  the 
same  way  as  an  ordinary  fibroid  polypus.  Barnes  recommends  the 
removal  of  these  masses  by  means  of  the  wire  ecraseur.  Before  their 
detection  the  os  uteri  must  be  opened  up. 

Retention  in  Utero  of  a  Blighted  Ovum. — The  cases  previously 
alluded  to,  in  which  an  ovum  has  perished  in  early  pregnancy  and  is 
retained  in  utero,  are  often  puzzling  and  may  give  rise  to  serious 
moral  and  medico-legal  questions.  The  blighted  ovum  may  be  re- 
tained for  many  months,  the  outside  limit,  according  to  McClintock,1 
by  whom  the  subject  has  been  ably  discussed,  being  nine  months. 
The  appearance  of  the  ovum  when  thrown  oif  will  give  no  reliable 
clue  to  the  length  of  time  which  has  elapsed  since  it  perished.  The 
symptoms  are  often  very  obscure.  Generally  there  have  been  the  usual 
indications  of  pregnancy  which,  with  or  without  signs  of  impending 
miscarriage,  disappear  or  are  modified,  and  then  follows  a  period  of 
ill-health,  with  pelvic  uneasiness,  and  irregular  metrorrhagia,  which 
may  be  mistaken  for  menstruation.  Occasionally,  but  by  no  means 
necessarily,  there  is  a  fcetid  discharge,  and  this  probably  exists  only 
when  the  membranes  have  broken,  and  air  has  access  to  the  ovum. 
In  some  cases  obscure  septicsemic  symptoms  have  been  observed. 
Such  symptoms  are  obviously  too  indefinite  to  lead  to  an  accurate 
diagnosis.  In  the  course  of  time  the  ovum  is  generally  thrown  off, 
with  more  or  less  hemorrhage.  If  the  nature  of  the  case  is  detected, 
ergot  may  be  given  to  promote  the  expulsion  of  the  uterine  contents, 
and  it  may  even  be  advisable  to  dilate  the  cervix  with  sponge  or 
laminaria  tents  and  remove  them  artificially. 

1  Sydenham  Society's  edition  of  Smel lie's  Midwifery,  vol.  i.  p.  169. 


264  PREGNANCY. 

Subsequent  Management  of  Abortion. — The  frequency  with 
which  abortion  leads  to  chronic  uterine  disease  should  lead  us  to 
attach  much  more  importance  to  the  subsequent  management  of  the 
patient  than  has  been  customary.  The  usual  practice  is  to  confine  the 
patient  to  bed  for  two  or  three  days  only,  and  then  to  allow  her  to 
resume  her  ordinary  avocations,  on  the  supposition  that  a  miscarriage 
requires  less  subsequent  care  than  a  confinement.  The  contrary  of  this 
is,  however,  most  probably  the  case ;  for  the  uterus  has  been  emptied 
when  it  is  unprepared  for  involution,  and  that  process  is  often  very 
imperfectly  performed.  We  should,  therefore,  insist  on  at  least  as 
much  attention  being  paid  to  rest  as  after  labor  at  term. 


CHAPTER    I. 

THE  PHENOMENA  OF  LABOR. 

Delivery  at  Term. — In  considering  delivery  at  term  Ave  have  to 
discuss  two  distinct  classes  of  events. 

One  of  these  is  the  series  of  vital  actions  brought  into  play  in  order 
to  effect  the  expulsion  of  the  child ;  and  the  other  consists  of  the  move- 
ments imparted  to  the  child — the  body  to  be  expelled — in  other  words, 
the  mechanism  of  delivery. 

Causes  of  Labor. — Before  proceeding  to  the  consideration  of  these 
important  topics,  a  few  words  may  be  said  as  to  the  determining  causes 
of  labor.  This  subject  has  been  from  the  earliest  times  a  qucestio  vexata 
among  physiologists ;  and  many  and  various  are  the  theories  which 
have  been  broached  to  explain  the  curious  fact  that  labor  sponta- 
neously commences,  if  not  at  a  fixed  epoch,  at  any  rate  approximately 
so.  It  must  be  admitted  that  even  yet  there  is  no  explanation  which 
can  be  implicitly  accepted. 

The  explanations  which  have  been  given  may  be  divided  into  two 
classes — those  which  attribute  the  advent  of  labor  to  the  fetus,  and 
those  which  refer  it  to  some  change  connected  with  the  maternal  gen- 
erative organs. 

The  former  is  the  opinion  which  was  held  by  the  older  accoucheurs, 
who  assigned  to  the  foetus  some  active  influence  in  effecting  its  own 
expulsion.  It  need  hardly  be  said  that  such  fanciful  views  have  no 
kind  of  physiological  basis.  Others  have  supposed  that  there  might 
be  some  change  in  the  placental  circulation,  or  in  the  vascular  system 
of  the  foetus,  which  might  solve  the  mystery. 

The  majority  of  obstetricians,  however,  refer  the  advent  of  labor  to 
purely  maternal  causes.  Among  the  more  favorite  theories  is  one, 
which  was  originally  started  in  this  country  [/.  e.,  England]  by  Dr. 
Power,  and  adopted  and  illustrated  by  Depaul,  Dubois,  and  other 
writers.  It  is  based  on  the  assumption  that  there  is  a  sphincter  action 
of  the  fibres  of  the  cervix,  analogous  to  that  of  the  sphincters  of  the 
bladder  and  rectum,  and  that  when  the  cervix  is  taken  up  into  the 
general  uterine  cavity  as  pregnancy  advances,  the  ovum  presses  upon 
it,  irritates  its  nerves,  and  so  sets  up  reflex  action,  which  ends  in  the 
establishment  of  uterine  contraction.  This  theory  was  founded  on 
erroneous  conceptions  of  the  changes  that  occurred  in  the  neck  of  the 

265 


266  LABOR. 

uterus ;  and,  as  it  is  certain  that  obliteration  of  the  cervix  does  not 
really  take  place  in  the  manner  that  Power  believed  when  his  theory 
was  broached,  it  is  obvious  that  its  supposed  result  cannot  follow.  A 
modification  of  this  theory  is  that  held  by  Stoltz  and  Bandl.  Accord- 
ing to  this  view,  when  the  cervix  softens  during  the  last  weeks  of 
pregnancy,  the  painless  uterine  contractions  of  gestation  act  upon  the 
os  intern  um,  and  open  it  sufficiently  to  admit  of  the  ovum  pressing  on 
the  lower  segment  of  the  uterus,  and  so  inducing  labor. 

Girin1  contends  that  the  descent  and  pressure  of  the  foetal  head  on 
the  os  internum  is  favored  by  changes  in  the  density  of  the  liquor 
amnii.  This  attains  its  maximum  density  in  the  early  months  of 
pregnancy,  when  it  is  1.030,  and  it  diminishes  steadily  until  term, 
when  it  is  nearly  that  of  water.  The  specific  gravity  of  the  foetus  is 
at  first  lower  than  that  of  the  amniotic  fluid,  but  becomes  steadily 
higher.  Eventually  the  foetus,  sinking  on  the  os  internum,  excites  the 
uterus  to  contraction. 

Extreme  distention  of  the  uterus  has  been  held  to  be  the  determining 
cause  of  labor,  a  view  lately  revived  by  Dr.  King,  of  Washington,2  who 
believes  that  contractions  are  induced  because  the  uterus  ceases  to  aug- 
ment in  capacity,  while  its  contents  still  continue  to  increase.  This 
hypothesis  is  sufficiently  disproved  by  a  number  of  clinical  facts  which 
show  that  the  uterus  may  be  subject  to  excessive  and  even  rapid  dis- 
tention— as  in  cases  of  hydramnios,  multiple  pregnancy,  and  hydatidi- 
form  degeneration  of  the  ovum — without  the  supervention  of  uterine 
contractions. 

Another  inciter  of  uterine  action  has  been  supposed  to  be  the  sepa- 
ration of  the  ovum  from  its  connection  to  the  uterine  parietes,  in 
consequence  of  fatty  degeneration  of  the  decidua  occurring  at  the  end 
of  pregnancy.  The  supposed  result  of  this  change,  which  undoubtedly 
occurs,  is  that  the  ovum  becomes  so  detached  from  its  organic  adhe- 
sions as  to  be  somewhat  in  the  position  of  a  foreign  body,  and  thus 
incites  the  nerves  so  largely  distributed  over  the  interior  of  the  uterus. 
This  theory,  which  has  been  widely  accepted,  was  originally  started  by 
Sir  James  Simpson,  who  pointed  out  that  some  of  the  most  efficient 
means  of  inducing  labor  (such,  for  example,  as  the  insertion  of  a  gum- 
elastic  catheter  between  the  ovum  and  the  uterine  walls)  probably  act 
in  the  same  way,  viz.,  by  effecting  separation  of  the  membranes  and 
detachment  of  the  ovum. 

Barnes  instances,  in  opposition  to  this  idea,  the  fact  that  ineffectual 
attempts  at  labor  come  on  at  the  natural  term  of  gestation  in  cases  of 
extra-uterine  pregnancy,  when  the  foetus  is  altogether  independent  of 
the  uterus,  and,  therefore,  he  argues,  the  cause  cannot  be  situated  in 
the  uterus  itself.  A  fair  answer  to  this  argument  would  be  that 
although,  in  such  cases,  the  womb  does  not  contain  the  ovum,  it  does 
contain  a  decidua,  the  degeneration  and  separation  of  which  might  suf- 
fice to  induce  the  abortive  and  partial  attempts  at  labor  then  witnessed. 

Leopold3  suggests  that  the  advent  of  labor  may  be  connected  with 

1  Arch,  de  Tocologie,  No.  8, 1889. 

a  American  Journal  of  Obstetrics,  1870-71,  vol.  HI.  p.  561 

»  "  Studien  liber  die  Schleimhaut,"  etc.    Arch.  f.  Gyn.,  1887,  Bd.  xi.  s.  443. 


THE    PHENOMENA    OF    LABOR.  267 

other  changes  in  the  decidua  which  occur  in  advanced  pregnancy.  He 
points  out  that  then  giant  cells,  containing  many  nuclei,  appear  in  the 
serotina  which  penetrate  the  uterine  sinuses,  and  cause  the  formation 
in  them  of  thrombi.  The  obstruction  in  the  calibre  of  a  number  of 
these  vessels  leads  to  a  stasis  of  the  maternal  blood  returning  from  the 
placenta,  and  to  an  increase  of  carbonic  acid  in  it,  which  may  excite 
the  motor  centre  for  uterine  contraction,  which  is  known  to  exist  in 
the  medulla  oblongata. 

Objections  to  These  Theories. — A  serious  objection  to  all  these 
theories,  which  are  based  on  the  assumption  that  some  local  irritation 
brings  on  contraction,  is  the  fact,  which  has  not  been  generally  appre- 
ciated, that  uterine  contractions  are  always  present  during  pregnancy 
as  a  normal  occurrence,  and  that  they  may  be,  and  often  are,  readily 
intensified  at  any  time,  so  as  to  result  in  premature  delivery. 

It  is,  indeed,  most  likely  that,  at  or  about  the  full  term,  the  nervous 
supply  of  the  uterus  is  so  highly  developed,  and  in  so  advanced  a  state 
of  irritability,  that  it  more  readily  responds  to  stimuli  than  at  other 
times.  If,  by  separation  of  the  decidua,  or  in  some  other  way,  stimu- 
lation of  the  excitor  nerves  is  then  effected,  more  frequent  and  forcible 
contractions  than  usual  may  result,  and,  as  they  become  stronger  and 
more  regular,  terminate  in  labor.  But,  allowing  this,  it  still  remains 
quite  unexplained  why  this  should  occur  with  such  regularity  at  a 
definite  time. 

Tyler  Smith  tried,  indeed,  to  prove  that  labor  came  on  naturally  at 
what  would  have  been  a  menstrual  epoch,  the  congestion  attending  the 
menstrual  nisus  acting  as  the  exciter  of  uterine  contraction.  He 
therefore  refers  the  onset  of  labor  to  ovarian,  rather  than  to  uterine, 
causes.  Although  this  view  is  upheld  with  all  its  author's  great 
talent,  there  are  several  objections  to  it  difficult  to  overcome.  Thus, 
it  assumes  that  the  periodic  changes  in  the  ovary  continue  during 
pregnancy,  of  which  there  is  no  proof.  Indeed,  there  is  good  reason 
to  believe  that  ovulation  is  suspended  during  gestation,  and  with  it,  of 
course,  the  menstrual  nisus.  Besides,  as  has  been  well  objected  to  by 
Cazeaux,  even  if  this  theory  were  admitted,  it  would  still  leave  the 
mystery  unsolved,  for  it  would  not  explain  why  the  menstrual  nisus 
should  act  in  this  way  at  the  tenth  menstrual  epoch,  rather  than  at  the 
ninth  or  eleventh. 

In  spite,  then,  of  many  theories  at  our  disposal,  it  is  to  be  feared 
that  we  must  admit  ourselves  to  be  still  in  entire  ignorance  of  the 
reason  why  labor  should  come  on  at  a  fixed  epoch. 

Mode  in  which  the  Expulsion  of  the  Child  is  Effected. — The 
expulsion  of  the  child  is  effected  by  the  contractions  of  the  muscular 
fibres  of  the  uterus,  aided  by  those  of  some  of  the  abdominal  muscles. 
These  efforts  are  in  the  main  entirely  independent  of  volition.  So  far 
as  regards  the  uterine  contractions,  this  is  absolutely  true,  for  the 
mother  has  no  power  of  originating,  lessening,  or  increasing  the  action 
of  the  uterus.  As  regards  the  abdominal  muscles,  however,  the  mother 
is  certainly  able  to  bring  them  into  action,  and  to  increase  their  power 
by  voluntary  efforts ;  but,  as  labor  advances,  and  as  the  head  passes 
into  the  vagina  and  irritates  the  nerves  supplying  it,  the  abdominal 


268  LABOR. 

muscles  are  often  stimulated  to  contract,  through  the  influence  of  reflex 
action,  independently  of  volition  on  the  part  of  the  mother. 

There  can  be  little  doubt  that  the  chief  agent  in  the  expulsion  of  the 
child  is  the  contraction  of  the  uterus  itself.  This  opinion  is  almost 
unanimously  held  by  accoucheurs,  and  the  influence  of  the  abdominal 
muscles  is  believed  to  be  purely  accessory  Dr.  Haughton,1  however, 
maintains  a  view  which  is  directly  contrary  to  this.  From  an  ex- 
amination of  the  force  of  the  uterine  contractions,  arrived  at  by 
measuring  the  amount  of  muscular  fibre  contained  in  the  walls  of  the 
uterus,  he  arrives  at  the  conclusion  that  the  uterine  contractions  are 
chiefly  influential  in  rupturing  the  membranes,  and  dilating  the  os 
uteri,*  bringing  into  action,  if  needful,  a  force  equivalent  to  54  pounds; 
but  when  this  is  effected,  and  the  second  stage  of  labor  has  commenced, 
he  thinks  the  remainder  of  the  labor  is  mainly  completed  by  the  con- 
tractions of  the  abdominal  muscles,  to  which  he  attributes  enormous 
powers,  equivalent,  if  needful,  to  a  pressure  of  523.65  pounds  on  the 
area  of  the  pelvic  canal. 

These  views  bear  on  a  topic  of  primary  consequence  in  the  physi- 
ology of  labor.  They  have  been  fully  criticised  by  Duncan,  who  has 
devoted  much  experimental  research  to  the  study  of  the  powers  brought 
into  action  in  the  expulsion  of  the  child.  His  conclusions  are  that,  so 
far  from  the  enormous  force  being  employed  that  Haughton  estimated, 
in  the  large  majority  of  cases  the  effective  force  brought  to  bear  on  the 
child  by  the  combined  action  of  both  the  uterine  and  abdominal  mus- 
cles is  less  than  50  pounds — that  is,  less  than  the  force  which  Haughton 
attributed  to  the  uterus  alone.  In  extremely  severe  labors,  when  the 
resistance  is  excessive,  he  thinks  that  extra  power  may  be  employed , 
but  he  estimates  the  maximum  as  not  above  80  pounds,  including  in  this 
total  the  action  of  both  the  uterine  and  abdominal  muscles.  Jouliu 
arrived  at  the  conclusion  that  the  uterine  contractions  were  capable  of 
resisting  a  maximum  force  of  about  one  hundredweight.  Both  these 
estimates,  it  will  be  observed,  are  much  under  that  of  Haughton,  which 
Duncan  describes  as  representing  "  a  strain  to  which  the  maternal 
machinery  could  not  be  subjected  without  instantaneous  and  utter 
destruction." 

There  are  many  facts  in  the  history  of  parturition  which  make  it 
certain  that  the  chief  factor  in  the  expulsion  of  the  child  is  the  uterus. 
Among  these  may  be  mentioned  occasional  cases  in  which  the  action  of 
the  abdominal  muscles  is  materially  lessened,  if  not  annulled — as  in 
profound  anaesthesia,  and  in  some  cases  of  paraplegia — in  which, 
nevertheless,  uterine  contractions  suffice  to  effect  delivery.  The  most 
familiar  example  of  its  influence,  however,  and  one  that  is  a  matter  of 
everyday  observation  in  practice,  is  when  inertia  of  the  uterus  exists. 
In  such  cases  no  effort  on  the  part  of  the  mother,  no  amount  of 
voluntary  action  that  she  can  bring  to  bear  on  the  child,  has  any 
appreciable  influence  on  the  progress  of  the  labor,  which  remains  in 
abeyance  until  the  defective  uterine  action  is  re-established,  or  until 
artificial  aid  is  given. 

i  '  On  the  Muscular  Forces  Employed  in  Parturition,"  etc.  Dublin  Quart.  Journ.  Med.  Sc.,  1870, 
vol.  xlxi.  p.  459. 


THE    PHENOMENA    OP    LABOR.  269 

Contraction  of  the  uterus,  then,  being  the  main  agent  in  delivery,  it 
is  important  for  us  to  appreciate  its  mode  of  action,  and  its  effect  on 
the  ovum. 

Uterine  Contractions  at  the  Commencement  of  Labor. — We 
have  seen  that  intermittent  and  generally  painless  uterine  contractions 
exist  during  pregnancy.  As  the  period  for  delivery  approaches,  these 
become  more  frequent  and  intense,  until  labor  actually  commences, 
when  they  begin  to  be  sufficiently  developed  to  effect  the  opening  up 
of  the  os  uteri,  with  a  view  to  the  passage  of  the  child.  They  are  now 
accompanied  by  pain,  which  increases  as  labor  advances,  and  is  so 
characteristic  that  "  pains  "  are  universally  used  as  a  descriptive  term 
for  the  contractions  themselves.  It  does  not  necessarily  follow  that 
uterine  contractions  are  painless  until  they  commence  to  effect  dilata- 
tion of  the  os  uteri.  On  the  contrary,  during  the  last  days  or  even 
weeks  of  pregnancy,  women  constantly  have  irregular  contractions, 
accompanied  by  severe  suffering,  which,  however,  pass  off  without  pro- 
ducing any  marked  effect  on  the  cervix.  When  labor  has  actually 
begun,  if  the  hand  is  placed  on  the  uterus,  when  a  pain  commences, 
the  contraction  of  its  muscular  tissue  is  very  apparent,  and  the  whole 
organ  is  observed  to  become  tense  and  hard,  the  rigidity  increasing 
until  the  pain  has  reached  its  acme,  the  uterine  walls  then  relaxing, 
and  remaining  soft  until  the  next  pain  comes  on.  At  the  commence- 
ment of  labor  these  pains  are  few,  separated  from  each  other  by  a  con- 
siderable interval,  and  of  short  duration.  In  a  perfectly  typical  labor 
the  interval  between  the  pains  becomes  shorter  and  shorter,  while,  at 
the  same  time,  the  duration  of  each  pain  is  increased.  At  first  they 
may  occur  only  once  in  an  hour  or  more,  while  eventually  there  may 
not  be  more  than  a  few  minutes7  interval  between  them. 

If,  when  the  pains  are  fairly  established,  a  vaginal  examination  be 
made,  the  os  uteri  may  be  found  to  be  thinned  and  dilated  in  propor- 
tion to  the  progress  of  the  labor.  During  the  contraction  the  bag  of 
membranes  will  be  felt  to  bulge,  to  become  tense  from  the  downward 
pressure  of  the  liquor  amnii  within  it,  and  to  protrude  through  the 
os  if  it  be  sufficiently  open.  The  membranes,  with  the  contained 
liquor  amnii,  thus  form  a  fluid  wedge,  which  has  a  most  important 
influence  in  dilating  the  os  uteri  (see  Frontispiece).  This  does  not, 
however,  form  the  sole  mechanism  by  which  the  os  uteri  is  dilated,  for 
it  is  also  acted  upon  by  the  contractions  of  the  muscular  fibres  of  the 
uterus,  which  tend  to  pull  it  open.  It  is  probable  that  the  muscular 
dilatation  of  the  os  is  effected  chiefly  by  the  longitudinal  fibres,  which, 
as  they  shorten,  act  upon  the  os  uteri,  the  part  where  there  is  least 
resistance. 

Partly  then  by  muscular  contraction,  partly  by  mechanical  pressure, 
the  cervical  canal  is  dilated,  and  as  it  opens  up  it  becomes  thinner  and 
thinner,  until  it  is  entirely  taken  up  into  the  uterine  cavity. 

There  is  no  longer  any  obstacle  to  the  passage  of  the  presenting  part 
of  the  child  into  the  cavity  of  the  pelvis,  and  the  force  of  the  pains 
now  generally  effects  the  rupture  of  the  membranes,  and  the  escape  of 
the  liquor  amnii.  There  is  often  observed,  at  this  time,  a  temporary 
relaxation  in  the  frequency  of  the  pains,  which  had  been  steadily 


270  LABOR. 

increasing ;  but  they  soon  recommence  with  increased  vigor.  If  the 
abdomen  be  now  examined,  it  will  be  observed  to  be  much  diminished 
in  size,  partly  in  consequence  of  the  escape  of  the  liquor  amnii,  partly 
from  the  descent  of  the  foetus  into  the  pelvic  cavity. 

The  character  of  the  pains  soon  changes.  They  become  stronger, 
longer  in  duration,  separated  by  a  shorter  interval,  and  accompanied 
by  a  distinct  forcing  effort,  being  generally  described  as  "  the  bearing 
down"  pains.  Now  is  the  time  at  which  the  accessory  muscles  of 
parturition  come  into  operation.  The  patient  brings  them  into  play  in 
the  manner  which  will  be  subsequently  described,  and  the  combined 
action  of  the  uterine  and  abdominal  muscles  continues  until  the  expul- 
sion of  the  child  is  effected. 

The  precise  mode  of  uterine  contraction  is  still  somewhat  a  matter 
of  dispute.  It  is  generally  described  as  commencing  in  the  cervix, 
passing  gradually  upward  by  peristaltic  action,  the  Avave  then  returning 
downward  toward  the  os  uteri.  This  view  was  maintained  by  AVigand, 
and  has  been  indorsed  by  Rigby,  Tyler  Smith,  and  many  other  writers. 
In  support  of  it  they  instance  the  fact  that,  on  the  accession  of  a  pain, 
the  presenting  part  first  recedes,  the  bag  of  membranes  then  becomes 
tense  and  protrudes  through  the  os,  and  it  is  not  untit  some  time  that 
the  presenting  part  of  the  child  itself  is  pushed  down.  It  is  very 
doubtful  if  this  view  is  correct ;  and  a  careful  examination  of  the  course 
of  the  pains  would  rather  lead  to  the  belief  that  the  contractions  com- 
mence at  the  fundus,  where  the  muscular  tissue  is  most  largely  de- 
veloped, and  gradually  proceed  downward  to  the  cervix,  the  waves  of 
contraction  being,  however,  so  rapid  that  the  whole  organ  seems  to 
harden  en  masse.  The  apparent  recession  of  the  presenting  part,  and 
the  bulging  of  the  bag  of  membranes,  are  certainly  no  proof  that  the 
contractions  begin  at  the  cervix ;  for  the  commencing  contraction  would 
necessarily  push  down  the  fluid  in  front  of  the  head,  and  cause  the 
membranes  to  bulge,  and  the  os  to  become  tense,  before  its  force  was 
brought  to  bear  on  the  foetus  itself.  Indeed,  did  the  contraction  com- 
mence at  the  lower  part  of  the  uterus,  we  should  expect  the  opposite  of 
what  takes  place  to  occur,  and  the  waters  to  be  pushed  upward, 
and  away  from  the  cervix.  The  fundal  origin  of  the  contraction  is 
further  illustrated  by  what  is  observed  when  the  hand  of  the  accoucheur 
is  placed  in  the  uterine  cavity,  as  often  happens  in  certain  cases  of  hem- 
orrhage or  turning ;  for  if  a  pain  then  comes  on,  it  will  be  felt  to  start 
at  the  fundus,  and  gradually  compress  the  hand  from  above  downward. 

Value  of  the  Intermittent  Character  of  the  Pains. — The  inter- 
mittent character  of  the  contractions  is  of  great  practical  importance. 
Were  they  continuous,  not  only  would  the  muscular  powers  of  the 
patient  be  rapidly  exhausted,  but  by  the  obliteration  of  the  vessels 
produced  by  the  musculir  contraction,  the  circulation  through  the 
placenta  would  be  interfered  with,  and  the  life  of  the  child  imperilled. 
Hence  one  of  the  chief  dangers  of  protracted  labor,  especially  after  the 
escape  of  the  liquor  amuii,  is  that  the  uterine  fibres  may  enter  into  a 
state  of  tonic  rigidity,  a  condition  that  cannot  be  long  continued  with- 
out serious  risks  both  to  the  mother  and  child. 

The  fact  that  the  uterine  contractions  are  altogether  involuntary 


THE    PHENOMENA    OF    LABOR.  271 

proves  them  to  be  excited — as  indeed  we  would  a  priori  infer  from  our 
knowledge  of  the  anatomical  arrangement  of  the  nerves  of  the  uterus — 
solely  by  the  sympathetic  system.  Still  it  is  a  fact  of  everyday  obser- 
vation that  they  can  be  largely  influenced  by  emotions.  Various 
stimuli  applied  to  the  spinal  system  of  nerves  (as,  for  example,  when 
the  mammae  are  irritated)  have  also  a  marked  effect  in  inducing  uterine 
contraction.  The  precise  mode  in  which  such  influence  is  conveyed  to 
the  uterus,  in  spite  of  the  numerous  experiments  which  have  been 
made  for  the  purpose  of  determining  how  far  labor  is  affected  by 
destruction  of  the  spinal  cord,  is  still  a  matter  of  doubt.  After  the 
foetus  has  passed  through  the  cervix,  the  spinal  nerves  distributed  to 
the  vagina  and  perineum  are  excited  by  the  pressure  of  the  pre- 
senting part,  and  through  them  the  accessory  powers  of  parturition  are 
chiefly  brought  into  play.  The  contraction  of  the  muscles  of  the 
vagina  itself  is  supposed  to  have  some  influence  in  favoring  the  ex- 
pulsion of  the  foetus  after  the  birth  of  part  of  the  body,  and  also  in 
promoting  the  expulsion  of  the  placenta.  In  the  lower  animals  the 
vagina  has  a  very  marked  contractile  property,  and  is,  in  some  of  them, 
the  main  agent  by  which  the  young  are  expelled.  In  the  human 
subject  this  influence  is  certainly  of  very  secondary  importance. 

Character  and  Sources  of  Pains  During  Labor. — The  amount  of 
suffering  experienced  during  labor  varies  much  in  different  cases,  and 
is  in  direct  proportion  to  the  nervous  susceptibility  of  the  patient. 
There  are  some  women  who  go  through  labor  with  little  or  no  pain  at 
all.  This  is  proved  by  the  cases  (of  which  there  are  numerous  authentic 
instances  recorded)  in  which  labor  has  commenced  during  sleep,  and 
the  child  has  been  actually  born  without  the  mother  awakening.  I  am 
acquainted  with  a  lady,  who  has  had  a  large  family,  who  assures  me 
that,  though  labor  is  accompanied  by  a  sense  of  pressure  and  dis- 
comfort, she  experiences  nothing  which  can  be  called  actual  pain.  Such 
a  happy  state  of  affairs  is,  however,  extremely  exceptional,  and,  in  the 
vast  majority  of  cases,  parturition  is  accompanied  by  intense  suffering 
during  its  whole  course,  in  some  cases  amounting  to  anguish  which  has 
probably  no  parallel  under  any  other  condition. 

The  precise  cause  of  the  pain  has  been  much  discussed,  and  is,  no 
doubt,  complex. 

In  the  early  stage  of  labor,  and  before  the  dilatation  of  the  os,  it  is 
chiefly  seated  in  the  back,  from  whence  it  shoots  around  the  loins  and 
down  the  thighs.  It  is  then  probably  produced,  partly  by  pressure 
on  the  nerve-filaments  caused  by  contraction  of  the  muscular  fibres  to 
which  they  are  distributed,  and  partly  by  stretching  and  dilatation  of 
the  muscular  tissue  of  the  cervix.  M.  Beau  believes  that  in  this  stage 
the  pain  is  not  produced,  strictly  speaking,  in  the  uterus  itself,  but  is 
rather  a  neuralgia  of  the  lumbo-abdominal  nerves.  The  pains  at  this 
time  are  generally  described  as  "  acute  "  and  "  grinding,"  terms  which 
sufficiently  well  express  their  nature.  In  highly  nervous  women  these 
pains  are  often  much  less  well  borne  than  those  of  a  later  stage,  and 
the  suffering  they  undergo  is  indicated  by  their  extreme  restlessness 
and  loud  cries  as  each  contraction  supervenes.  As  the  os  dilates,  and 
the  labor  advances  into  the  expulsive  stage,  other  sources  of  suffering 
are  added. 


272  LABOR. 

The  presenting  part  now  passes  into  the  vagina  and  presses  on  the 
vaginal  nerves,  as  well  as  on  the  large  nervous  plexuses  lying  in  the 
pelvis.  As  it  descends  lower  it  stretches  the  perineum  and  vulva,  and 
presses  on  the  bladder  and  rectum.  Hence  cramps  are  produced  in 
the  muscles  supplied  by  the  nerve  plexuses,  as  well  as  an  intolerable 
sense  of  tearing  and  stretching  in  the  vulva  and  perineum,  and  often 
a  distressing  feeling  of  tenesmus  in  the  bowels.  By  this  time  the 
accessory  muscles  of  parturition  are  brought  into  action,  and  they,  as 
well  as  the  uterine  muscles,  are  thrown  into  frequent  and  violent  con- 
tractions, which,  independently  of  the  other  causes  mentioned,  are 
sufficient  of  themselves  to  produce  great  pain,  likened  to  that  of  colic, 
produced  by  involuntary  and  repeated  contraction  of  the  muscles  of 
the  intestines. 

Taking  all  these  causes  into  consideration,  there  is  no  lack  of  suffi- 
cient explanation  of  the  intolerable  suifering  which  is  so  constant  an 
accompaniment  of  childbirth. 

Effect  of  the  Pains  on  the  Mother  and  Foatus. — The  effect  of  the 
pains  on  the  mother's  circulation  is  well  marked.  The  rapidity  of  the 
pulse  increases  distinctly  with  each  contraction,  and,  as  the  pain  passes 
off,  it  again  declines  to  its  former  state.  A  similar  observation  has 
been  made  with  regard  to  the  sounds  of  the  foetal  heart,  especially  after 
the  expulsion  of  the  liquor  ainnii.  Hicks  has  pointed  out  that  during 
a  pain  the  muscular  vibrations  give  rise  to  a  sound  which  often 
resembles  that  of  the  fcetal  heart,  and  which  completely  disappears 
when  the  muscular  tissue  relaxes.  The  effect  of  the  pain  in  intensi- 
fying the  uterine  souffle  has  been  already  mentioned.  The  strong 
muscular  efforts  would  naturally  lead  us  to  expect  a  marked  elevation 
of  temperature  during  labor.  Further  observations  on  this  point  are 
required ;  but  Squire  asserts  that  there  is  generally  only  a  very  slight 
increase  in  temperature  during  delivery,  rapidly  passing  off  as  soon  as 
labor  is  over. 

Division  of  Labor  into  Stages. — Such  being  the  physiological 
facts  in  connection  with  the  labor  pains,  we  may  now  describe  the 
ordinary  progress  of  a  natural  labor — that  is,  one  terminated  by  the 
natural  powers,  and  with  a  head  presenting. 

For  facility  of  description  obstetricians  have  long  been  in  the  habit 
of  dividing  the  course  of  labor  into  stages,  which  correspond  pretty 
accurately  with  the  natural  sequence  of  events.  For  this  purpose  we 
generally  talk  of  three  stages  :  viz.  (1)  from  the  commencement  of 
regular  pains  until  the  complete  dilatation  of  the  cervix  (stage  of  efface- 
ment  and  dilatation) ;  (2)  from  the  complete  dilatation  of  the  cervix 
until  the  expulsion  of  the  child  (stage  of  expulsion)  ;  (3)  the  concluding 
stage,  comprising  the  permanent  contraction  of  the  uterus,  and  the 
separation  and  expulsion  of  the  placenta  (stage  of  the  after-birth).  To 
these  we  may  conveniently  add  a  preparatory  stage,  antecedent  to  the 
regular  commencement  of  the  labor. 

Preparatory  Stage. — For  a  short  time  before  delivery,  varying 
from  a  few  days  to  a  week  or  two,  certain  premonitory  symptoms 
generally  exist,  which  indicate  the  approaching  advent  of  labor.  Some- 
times they  are  well  marked,  and  cannot  be  mistaken  ;  at  others  they 


THE    PHENOMENA    OF    LABOR.  273 

are  so  slight  as  to  escape  observation.  Amongst  the  most  common  is 
a  sinking  of  the  uterus  into  the  pelvic  cavity,  resulting  from  the  relax- 
ation of  the  soft  parts  proceeding  delivery.  The  result  is  that  the 
upper  edge  of  the  uterine  tumor  is  less  high  than  before,  and  in  con- 
sequence the  pressure  on  the  respiratory  organs  is  diminished,  and 
the  woman  often  feels  lighter  and  altogether  less  unwieldy  than  in 
the  previous  weeks.  If  a  vaginal  examination  be  made  at  this  time, 
the  lower  segment  of  the  uterus  will  be  found  to  have  sunk  lower  into 
the  pelvic  cavity;  and  the  consequence  of  this  is  that,  while  the  respira- 
tion is  less  embarrassed  and  the  patient  feels  less  bulky,  other  accom- 
paniments of  pregnancy,  such  as  hemorrhoids,  irritability  of  the 
bladder  and  bowels,  and  oedema  of  the  limbs,  become  aggravated. 
The  increased  pressure  on  the  bowels  often  induces  a  sort  of  temporary 
diarrhoea,  which  is  so  far  advantageous  that  it  empties  the  bowels  of 
feces  which  may  have  collected  within  them.  As  has  already  been 
pointed  out,  the  contractions  which  have  been  going  on  at  intervals 
during  the  latter  months  of  pregnancy  now  get  more  and  more  marked, 
and  they  have  the  effect  of  producing  a  real  shortening  of  the  cervix, 
which  is  of  great  value  preparatory  to  its  dilatation.  More  marked 
mucous  discharge  from  the  cavity  of  the  cervix  also  generally  occurs 
a  short  time  before  labor,  and  it  is  not  infrequently  tinged  with  blood 
from  the  laceration  of  minute  capillary  vessels.  The  discharge,  popu- 
larly known  as  the  "shows"  is  a  pretty  sure  sign  that  labor  is  not  far 
off.  It  may,  however,  be  entirely  absent,  even  until  the  birth  of  the 
child.  When  copious,  it  serves  to  lubricate  the  passages,  and  is 
generally  coincident  with  rapid  dilatation  of  the  parts  and  a  speedy 
labor. 

During  this  time  (premonitory  stage)  painful  uterine  contractions  are 
often  present,  which,  however,  have  no  effect  in  dilating  the  cervix. 
In  some  cases  they  are  frequent  and  severe,  and  are  very  apt  to  be 
mistaken  for  the  commencement  of  real  labor.  Such  "fake  pains,"  as 
they  are  termed,  are  often  excited  and  kept  up  by  local  irritations, 
such  as  a  loaded  or  disordered  state  of  the  intestinal  canal ;  and  they 
frequently  give  rise  to  considerable  distress,  and  much  inconvenience 
both  to  the  patient  and  practitioner.  They  are,  it  should  be  remem- 
bered, only  the  normal  contractions  of  the  uterus  intensified  and  accom- 
panied with  pain. 

First  Stage,  or  Dilatation. — As  labor  actually  commences,  the 
uterine  contractions  become  stronger,  and  the  fact  that  they  are  "  true" 
pains  can  be  ascertained  by  their  effect  on  the  cervix.  If  a  vaginal 
examination  be  made  during  one  of  these,  the  membranes  will  be  felt 
to  become  tense  and  bulging  during  the  pain,  and  the  os  uteri  will  be 
found  partially  dilated,  and  thinned  at  its  edges.  As  labor  advances 
this  effect  on  the  os  becomes  more  and  more  marked.  At  first  the 
dilatation  is  very  slight,  perhaps  not  more  than  enough  to  admit  the 
tip  of  the  examining  finger,  and  both  the  upper  and  lower  orifices  of 
the  cervix  can  be  made  out.  As  the  pains  get  stronger  and  more  fre- 
quent, dilatation  proceeds  in  the  way  already  described,  and  the  cervix 
gets  more  thin  and  tense,  until  we  can  feel  a  thin  circular  ring  (which 
is  lax  between  the  pains,  but  becomes  rigid  and  tense  during  the 

18 


274  LABOR. 

contraction  when  the  bag  of  waters  bulges  through  it),  without  any 
distinction  between  the  upper  and  lower  orifices.  During  this  time 
the  patient,  although  she  may  be  suffering  acutely,  is  generally  able 
to  sit  up  and  walk  about.  The  amount  of  pain  experienced  varies 
much  according  to  the  character  of  the  patient.  In  emotional  women 
of  highly  developed  nervous  susceptibilities  it  is  generally  very  great. 
They  are  restless,  irritable,  and  desponding,  and  when  the  pain  comes 
on  cry  out  loudly.  The  character  of  the'  cry  is  peculiar  and  well 
marked  during  the  first  stage,  and  has  constantly  been  described  by 
obstetric  writers  as  characteristic.  It  is  acute  and  high,  and  is  cer- 
tainly very  different  from  the  deep  groans  of  the  second  stage,  when 
the  breath  is  involuntarily  retained  to  assist  the  parturient  effort. 
When  dilatation  is  nearly  completed  various  reflex  nervous  phenomena 
often  show  themselves.  One  of  these  is  nausea  and  vomiting,  another 
is  uncontrollable  shivering,  which  is  not  accompanied  by  a  sense  of 
coldness,  the  patient  being  often  hot  and  perspiring.  Both  these 
symptoms  indicate  that  the  propulsive  stage  will  shortly  commence ; 
and  they  may  be  regarded  as  favorable  rather  than  otherwise,  although 
they  are  apt  to  alarm  the  patient  and  her  friends.  By  this  time  the 
os  is  fully  dilated,  the  membranes  generally  rupture  spontaneously,  and 
a  considerable  portion  of  the  liquor  arnuii  flows  away.  The  head,  if 
presenting,  often  acts  as  a  sort  of  ball-valve,  and,  falling  down  on 
the  aperture  of  the  cervix,  prevents  the  complete  evacuation  of  the 
liquor  amnii,  which  escapes  by  degrees  during  the  rest  of  the  labor, 
or  may  be  retained  in  considerable  quantity  until  the  birth  of  the 
child. 

It  not  infrequently  happens,  if  the  membranes  are  somewhat  tougher 
than  usual  and  the  pains  frequent  and  strong,  that  the  foetus  is  pushed 
through  the  pelvis,  and  even  expelled  surrounded  by  the  membranes. 
When  this  occurs  the  child  is  said  to  be  born  with  a  "  caul,"  and  this 
event  would  doubtless  happen  more  frequently  than  it  does  were  it  not 
the  custom  of  the  accoucheur  to  rupture  the  membranes  artificially  as 
soon  as  the  os  is  completely  opened  up,  after  which  time  their  integrity 
is  no  longer  of  any  value. 

Second  Stage,  or  Propulsion. — The  os  is  now  entirely  retracted 
over  the  presenting  part,  and  is  no  longer  to  be  felt,  the  vagina  and 
the  uterine  cavity  forming  a  single  canal.  Xow  the  mucous  discharge 
is  generally  abundant,  so  that  the  examining  finger  brings  away  long 
strings  of  glairy,  transparent  mucus  tinged  with  blood.  The  pains, 
after  a  short  interval  of  rest,  become  entirely  altered  in  character. 
The  uterus  contracts  tightly '  round  the  foetus,  the  presenting  part 
descends  into  the  pelvis,  and  the  true  propulsive  pains  commence. 
The  accessory  muscles  of  parturition  now  come  into  play.  With  each 
pain  the  patient  takes  a  deep  inspiration,  and  thus  fills  the  chest  so  as 
to  give  a  point  d'appui  to  the  abdominal  muscles.  For  the  same 
reason  she  involuntarily  seizes  hold  of  some  point  of  support,  as  the 
hand  of  a  bystander  or  a  towel  tied  to  the  bed,  and,  at  the  same  time, 
pushes  with  her  feet  against  the  end  of  the  bed,  and  so  is  able  to  bear 
down  to  advantage.  The  cries  are  no  longer  sharp  and  loud,  but 
consist  of  a  series  of  deep  suppressed  groans,  which  correspond  to  a 


THE    PHENOMENA    OF    LABOR.  275 

succession  of  short  expirations  made  during  the  straining  effort.  In 
this  way  the  abdominal  muscles  contract  forcibly  on  the  uterus,  which 
they  further  stimulate  to  action  by  pressing  upon  it.  It  is  to  be 
observed  that  these  straining  efforts  are,  to  a  considerable  extent,  under 
the  control  of  the  patient.  By  encouraging  her  to  hold  her  breath 
and  bear  down  they  can  be  intensified ;  while  if  we  wish  to  lessen 
them  we  can  advise  her  to  call  out,  and  when  she  does  so  the  abdom- 
inal muscles  have  no  longer  a  fixed  point  of  action.  Although  the 
patient  may  thus  lessen  the  effect  of  these  accessory  muscles,  it  is 
entirely  out  of  her  power  to  stop  their  action  altogether.  As  labor 
advances  the  head  descends  lower  and  lower,  receding  somewhat  in  the 
intervals  between  the  pains,  until  eventually  it  conies  down  on  the 
perineum,  which  it  soon  distends. 

The  pains  now  get  stronger  and  more  frequent,  often  with  scarcely 
a  perceptible  interval  between  them,  until  the  perineum  gets  stretched 
by  the  advancing  head.  In  the  interval  between  the  pains  the  elas- 
ticity of  the  perineal  structures  pushes  the  head  upward,  so  as  to 
diminish  the  tension  to  which  the  perineum  is  subjected,  the  next  pain 
again  putting  it  on  the  stretch  and  protruding  the  head  a  little  further 
than  before.  By  this  alternate  advance  and  recession  the  gradual 
yielding  of  the  structures  is  favored  and  risk  of  laceration  greatly 
diminished.  During  this  time  the  pressure  of  the  head  mechanically 
empties  the  bowel  of  its  contents.  During  the  last  pains,  when  the 
perineum  is  stretched  to  the  utmost,  the  anal  aperture  is  dilated,  some- 
times to  the  size  of  a  [silver  dollar]  ;  and  in  this  way  the  perineum 
is  relaxed,  just  as  the  distention,  and  consequent  risk  of  laceration, 
are  at  their  maximum.  The  apex  of  the  head  now  protrudes  more 
and  more  through  the  vulva,  surrounded  by  the  orifice  of  the  vagina, 
and  eventually  it  glides  over  the  perineum  and  is  expelled.  The  in- 
tensity of  the  suffering  at  this  moment  generally  causes  the  patient  to 
call  out  loudly.  The  force  of  the  abdominal  muscles  is  thus  lessened 
at  the  last  moment,  and  this,  in  combination  with  the  relaxation  of 
the  sphincter  ani,  forms  an  admirable  contrivance  for  lessening  the 
risk  of  perineal  injury.  The  rest  of  the  body  is  generally  expelled 
immediately  by  a  single  pain,  and  with  it  are  discharged  the  remains 
of  the  liquor  amnii,  and  some  blood-clots  from  separation  of  the 
placenta ;  and  so  the  second  stage  of  labor  terminates. 

The  Third  Stage. — The  third  stage  commences  after  the  expulsion 
of  the  child.  It  is  of  paramount  importance  to  the  safety  of  the 
mother  that  it  should  be  conducted  in  a  natural  and  efficient  manner ; 
for  it  is  now  that  the  uterine  sinuses  are  closed,  and  the  frail  barrier 
bv  which  nature  effects  this  may  be  very  readily  interfered  with,  and 
serious  and  even  fatal  loss  of  blood  ensue.  Unfortunately,  it  is  too 
often  the  case  that  the  practitioner's  entire  attention  is  fixed  on  the 
expulsion  of  the  child,  so  that  the  natural  history  of  the  rest  of  delivery 
is  very  generally  imperfectly  studied  and  understood. 

As  soon  as  the  child  is  expelled,  the  uterine  fibres  contract  in  all 
directions,  and  the  hand,  following  the  uterus  down,  will  find  that  it 
forms  a  firm  rounded  mass  lying  in  the  lower  part  of  the  abdominal 
cavity.  By  retraction  of  its  internal  surface  the  placental  attachments, 


276 


LABOR. 


which  probably  remain  undisturbed  until  the  expulsion  of  the  child, 
are  generally  separated,  and  the  after-birth  remains  in  the  cavity  of 
the  uterus  as  a  foreign  body. 

The  escape  of  blood  from  the  open  mouths  of  the  uterine  sinuses 
is  now  prevented  in  two  ways,  viz. :  (1)  by  the  contractions  of  the 
uterine  walls,  and  the  more  firm,  persistent,  and  tonic  this  is,  the  more 
certain  is  the  immunity  from  hemorrhage ;  (2)  by  the  formation  of 
coagula  in  the  mouths  of  the  vessels.  Any  undue  haste  in  promoting 
the  expulsion  of  the  placenta  tends  to  prevent  the  latter  of  these  two 
haemostatic  safeguards,  and  is  apt  to  be  followed  by  loss  of  blood. 
After  a  certain  time,  averaging  from  a  quarter  to  half  an  hour,  the 
uterus  will  be  felt  to  harden,  and,  if  the  case  be  solely  left  to  Nature, 
what  has  been  aptly  called  a  miniature  labor  occurs.  Pains  come  on, 
and  the  placenta  is  spontaneously  expelled  from  the  uterus,  either  into 
the  canal  of  the  vagina  or  even  externally.  In  most  obstetric  works 
it  is  stated  that  the  after-birth  may  be  separated  either  from  its  centre 
or  edge,  and  that  it  is  very  generally  expelled  through  the  os  in  an 
inverted  form,  with  its  foetal  surface  downward,  and  folded  transversely 
on  itself.  That  this  is  the  mode  in  which  the  placenta  is  often  ex- 
pelled, when  traction  on  the  cord  is  practised,  is  a  matter  of  certainty. 
It  then  passes  through  the  os  very  much  in  the  shape  of  an  inverted 
umbrella.  It  is  certain,  however,  that  this  is  not  the  natural  mechanism 
of  its  delivery.  The  subject  has  been  well  studied  by  Berry  Hart,1 
who  has  shown  that  during  the  contractions  of  the  third  stage  of  labor 
the  placenta  is  "  thrown  into  heights  and  hollows,"  and,  if  the  case 
be  left  entirely  to  Nature,  it  descends  with  its 
edge  or  a  point  near  its  edge  first,  its  uterine 
and  detached  surface  gliding  along  the  inner 
surface  of  the  uterus,  the  foldings  of  its  structure 
being  parallel  to  the  long  diameter  of  the  uterine 
cavity  (Fig.  100).  In  this  way  it  is  expelled 
into  the  vagina,  and  during  the  process  little 
or  no  hemorrhage  occurs.  \VTien  the  placenta  is 
drawn  out  in  the  way  too  generally  practised,  it 
obstructs  the  aperture  of  the  os,  and,  acting  like 
the  piston  of  a  pump,  tends  to  promote  hemor- 
rhage. The  corollaries  as  to  treatment  drawn 
from  these  facts  will  be  subsequently  considered. 
I  am  anxious,  however,  here  to  direct  attention 
to  Nature's  mechanism,  because  I  believe  there  is 
no  part  of  labor  about  the  management  of  which 
erroneous  views  are  more  prevalent  than  that  of 
this  stage,  and  none  in  which  they  are  more  apt 
to  lead  to  serious  consequences ;  and  unless  the 
mode  in  which  Nature  effects  the  expulsion  of 
the  placenta  and  prevents  hemorrhage  is  thor- 
oughly understood,  we  shall  certainly  fail  in  assisting  her  in  a  proper 
In  the  large  proportion  of  cases,  when  left  entirely  to  them- 


PlG.  100. 


Mode  in  which  the  pla- 
centa is  naturally  expelled. 
(After  DUNCAN.) 


manner. 


1  Berry  Hart:  "  Sectional  Anatomy  of  Labor."    Edin.  Med.  Journ.,  November,  1887. 


THE    PHENOMENA    OF    LABOR.  277 

selves,  the  placenta  would  be  retained,  if  not  in  the  uterus  at  any  rate 
in  the  vagina,  for  a  considerable  time — possibly  for  several  hours ; 
and  such  delay  would  very  unnecessarily  tire  the  patience  of  the  prac- 
titioner and  be  prejudicial  to  the  patient.  It  is,  therefore,  our  duty 
in  the  majority  of  cases  to  promote  the  expulsion  of  the  after-birth  ; 
and  when  this  is  properly  and  scientifically  done,  we  increase  rather 
than  diminish  the  patient's  safety  and  comfort.  But  in  order  to  do 
this  we  must  assist  Nature,  and  not  act  in  opposition  to  her  method, 
as  is  so  often  the  case. 

After-pains. — When  once  the  placenta  is  expelled  the  uterus  con- 
tracts still  more  firmly,  and  in  a  typical  case  is  felt  just  within  the 
pelvic  brim,  hard  and  firm,  and  about  the  size  of  a  cricket-ball.  Gen- 
erally for  several  hours,  or  even  for  one  or  two  days,  it  occasionally 
relaxes  and  contracts,  and  these  contractions  gives  rise  to  the  "  after- 
pains"  from  which  women  often  suffer  much.  The  object  of  these 
pains  is  no  doubt  to  expel  any  coagula  that  may  remain  in  the  uterus, 
and,  therefore,  however  unpleasant  they  may  be  to  the  patient,  they 
must  be  considered,  unless  very  excessive,  to  be  salutary  rather  than 
otherwise. 

Duration  of  Labor. — The  length  of  labor  varies  extremely  in 
different  cases,  and  it  is  quite  impossible  to  lay  down  any  definite  rules 
with  regard  to  it.  Subject  to  exceptions,  labor  is  longer  in  primiparse 
than  in  multipart,  on  account  of  the  greater  resistance  of  the  soft  parts 
to  the  former,  especially  of  the  structures  about  the  vagina  and  vulva. 
It  is  also  generally  stated  that  the  difficulty  of  labor  increases  with  the 
age  of  the  patient,  and  that  in  elderly  primiparse  it  is  likely  to  be 
unusually  tedious,  from  rigidity  of  the  soft  parts.  It  is  very  doubtful 
if  this  opinion  has  any  real  basis,  and  in  such  cases  the  practitioner 
often  finds  himself  agreeably  disappointed  in  the  result.  Mr.  Roper,1 
indeed,  argues  that  the  wasting  of  the  tissues  which  occurs  after  forty 
years  of  age  diminishes  their  resistance,  and  that  first  labors  after  that 
age  are  easier,  as  a  rule,  than  in  early  life.  The  habits  and  mode  of 
life  of  patients  have  no  doubt  a  considerable  influence  on  the  duration 
of  labor,  but  we  are  not  in  possession  of  any  very  reliable  facts  with 
regard  to  this  subject.  It  is  reasonable  to  suppose  that  the  tissues  of 
large,  muscular,  strongly-developed  women  will  offer  more  resistance 
than  those  of  slighter  build.  On  the  other  hand,  women  of  the  latter 
class,  especially  in  the  upper  ranks  of  life,  more  often  develop  nervous 
susceptibilities,  which  may  be  expected  to  influence  the  length  of  their 
labors.  The  average  duration  of  labor,  calculated  from  a  large  number 
of  cases,  is  from  eight  to  ten  hours ;  even  in  primiparae,  however,  it  is 
constantly  terminated  in  one  or  two  hours  from  its  commencement, 
and  may  be  extended  to  twenty-four  hours  without  any  symptoms  of 
urgency  arising.  In  multipart  it  is  frequently  over  in  even  a  shorter 
time.  Indications  calling  for  interference  may  arise  at  any  time  during 
the  progress  of  labor,  independently  of  its  length.  The  proportion 
between  the  length  of  the  first  and  second  stages  also  varies  consider- 
ably. The  first  stage  is  generally  the  longest,  and  it  is  stated  by 

»  Obst.  Trans.,  1886,  vol.  vii.  p.  51. 


278  LABOR. 

Cazeaux  to  be  normally  about  twice  the  length  of  the  second.  This  is 
probably  under  the  mark,  and  I  believe  Joulin  to  be  nearer  the  truth 
in  stating  that  the  first  stage  should  be  to  the  second  as  four  or  five  to 
one,  rather  than  as  two  to  one.  Often  when  the  first  stage  has  been 
very  prolonged,  the  second  is  terminated  rapidly. 

The  practitioner  is  constantly  asked  as  to  the  probable  length  of 
labor,  and  the  uncertainty  of  this  should  always  lead  him  to  give  a  most 
guarded  opinion.  Even  when  labor  is  progressing  apparently  in  the  most 
satisfactory  manner  the  pains  frequently  die  away,  and  delivery  may 
be  delayed  for  many  hours.  In  the  first  stage  a  cervix  that  is  appa- 
rently rigid  and  unyielding  may  rapidly  and  unexpectedly  dilate,  and 
delivery  soon  follow.  In  either  case,  if  the  practitioner  has  committed 
himself  to  a  positive  opinion  he  is  apt  to  incur  blame,  and  it  is  far 
better  always  to  be  extremely  cautious  in  our  predictions  on  this  point. 

Period  of  the  Day  at  which  Labor  Occurs. — A  somewhat  larger 
proportion  of  deliveries  occur  in  the  early  hours  of  the  morning  than 
at  other  times.  Thus  West1  found  that  out  of  2019  deliveries,  780 
took  place  from  11  P.M.  to  7  A.M.,  662  from  7  A.M.  to  3  P.M.,  and  577 
from  3  P.M.  to  11  P.M. 


CHAPTEE    II. 

MECHANISM  OF  DELIVERY  IN   HEAD   PRESENTATIONS. 

Importance  of  the  Subject. — It  is  quite  impossible  to  over-esti- 
mate the  importance  of  thoroughly  understanding  the  mechanism  of 
the  passage  of  the  foetus  through  the  pelvis.  This  dominates  the  whole 
scientific  practice  of  midwifery,  and  the  practitioner  cannot  acquire 
more  than  a  merely  empirical  knowledge,  such  as  may  be  possessed 
by  any  uneducated  midwife,  or  conduct  the  more  difficult  cases  requir- 
ing operative  interference,  with  safety  to  the  patient  or  satisfaction  to 
himself,  unless  he  thoroughly  masters  the  subject. 

In  treating  of  the  physiological  phenomena  of  labor  it  was  assumed 
that  Ave  had  to  da  with  an  ordinary  case  of  head  presentation,  the 
description  being  applicable,  with  slight  variations,  to  presentations  of 
other  parts  of  the  foetus.  So  in  discussing  the  mechanical  phenomena 
of  delivery,  I  shall  describe  more  in  detail  the  mechanism  of  head  pre- 
sentations, reserving  any  account  of  the  mechanism  of  other  presenta- 
tions until  they  are  separately  studied.  Head  presentation  is  so  much 
more  frequent  than  that  of  any  other  part — amounting  to  95  per  cent, 
of  all  cases — that  this  mode  of  studying  the  subject  is  fully  justified  ; 
and,  when  once  the  student  has  mastered  the  phenomena  of  delivery 

1  Amer.  Med.  Journ.,  1854. 


DELIVERY    IN    HEAD    PRESENTATIONS.  279 

in  head  presentations,  he  will  have  little  difficulty  in  understanding 
the  mechanism  of  labor  when  other  parts  of  the  foetus  present,  based, 
as  it  always  is,  on  the  same  general  plan. 

Mode  of  Recognizing-  the  Position  of  the  Head  by  its  Sutures 
and  Pontanelles. — In  entering  on  this  study  we  come  to  appreciate 
the  importance  of  the  sutures  and  fontanelles  in  enabling  us  to  detect 
the  position  of  the  foetal  head,  and  to  watch  its  progress  through  the 
pelvis;  and  unless  the  tactus  eruditus  by  which  these  can  be  dis- 
tinguished from  each  other  has  been  acquired,  the  practitioner  will  be 
unable  to  satisfy  himself  of  the  exact  progress  of  the  labor.  Nor  is 
this  always  easy.  Indeed,  it  requires  considerable  experience  and 
practice  before  it  is  possible  to  make  out  the  position  of  the  head  with 
absolute  certainty;  but  this  knowledge  should  always  be  aimed  at,  and 
the  student  will  never  regret  the  time  and  trouble  he  spends  in  ac- 
quiring it. 

At  the  commencement  of  labor  the  long  diameter  of  the  head  lies  in 
almost  any  diameter  of  the  pelvic  brim,  except  in  the  antero-posterior, 
where  there  is  not  space  for  it.  In  the  large  majority  of  cases,  how- 
ever, it  enters  the  pelvis  in  one  or  other  of  the  oblique  diameters,  or 
in  one  between  the  oblique  and  transverse ;  but  until1  it  has  fairly 
passed  through  the  brim,  it  more  frequently  lies  directly  in  the  trans- 
verse diameter  than  has  been  generally  supposed.  Hence  obstetricians 
are  in  the  habit  of  describing  the  head  as  lying  in  four  positions 
according  to  the  parts  of  the  pelvis  to  which  the  occiput  points ;  the 
first  and  third  positions  being  those  in  which  the  long  diameter  of  the 
head  occupies  the  right  oblique  diameter  of  the  pelvis,  the  second  and 
fourth  those  in  which  it  lies  in  the  left  oblique.  Many  subdivisions 
of  these  positions  have  been  made,  which  only  complicate  the  subject, 
and  render  it  more  difficult  to  understand. 

Pour  Positions  Described. — The  positions,  then,  of  the  foetal  head 
after  it  has  entered  the  brim,  which  it  is  of  importance  to  be  able  to 
distinguish  in  practice,  are  : 

First  (left  occipito-anterior,  qccipito-lccva  anterior,  O.L,.A.).  The  occiput 
points  to  the  left  foramen  ovale,  the  sinciput  to  the  right  sacro-iliac 
synchondrosis,  and  the  long  diameter  of  the  head  lies  in  the  right 
oblique  diameter  of  the  pelvis. 

Second  (right  occipito- anterior,  occipito-dextra  anterior,  O.D.A.).  The 
occiput  points  to  the  right  foramen  ovale,  the  forehead  to  the  left 
sacro-iliac  synchondrosis,  and  the  long  diameter  of  the  head  lies  in  the 
left  oblique  diameter  of  the  pelvis. 

Third  (right  occipito-posterior,  oceipito-dextra  posterior,  O.D.P.).  The 
occiput  points  to  the  right  sacro-iliac  synchondrosis,  the  forehead  to  the 
left  foramen  ovale,  and  the  long  diameter  of  the  head  lies  in  the  right 
oblique  diameter  of  the  pelvis.  The  position  is  the  reverse  of  the  first. 

Fourth  (left  occipito-posterior,  occipito-lceva  posterior,  O.L.P.).  The 
occiput  points  to  the  left  sacro-iliac  synchondrosis,  the  forehead  to  the 
right  foramen  ovale,  and  the  long  diameter  of  the  head  lies  in  the  left 
oblique  diameter  of  the  pelvis.  The  position  is  the  reverse  of  the  second. 

The  relative  frequency  of  these  positions  has  long  been,  and  still  is, 
a  matter  of  discussion  among  obstetricians.  According  to  Naegele,  to 


280 


LABOR. 


whose  classical  essay  we  owe  the  greater  part  of  our  knowledge  of  the 
subject,  the  head  lies  in  the  right  oblique  diameter  in  99  per  cent,  of 
all  cases.  More  recent  researches  have  thrown  some  doubt  on  the 
accuracy  of  these  figures,  and  many  modern  obstetricians  believe  that 
the  second  (O.D.A.)  position,  which  Naegele  believed  only  to  be  ob- 
served as  a  transitional  stage  in  the  natural  progress  of  the  third 
(O.D.P.)  position,  is  much  more  common  than  he  supposed.  This 
question  will  be  more  fully  discussed  when  we  treat  of  the  mechanism 
of  occipito-posterior  delivery,  and,  in  the  meantime,  it  may  serve  to 
show  the  discrepancy  which  exists  in  the  opinions  of  modern  waiters, 
if  we  append  the  following  table  of  the  relative  frequency  of  the 
various  positions,1  copied  from  Leishrnan's  work  : 


First 
position 
(O.L.A.) 

Second 
position 
IO.D.A.) 

Third 
position 
(O.D.P  ) 

Fourth 
position 
(O.L.P.) 

Not 
classified. 

70.00 

29.00 

1  00 

64.64 

32.88 

2.47 

Simpson  and  Barry      .... 
Dubois          

76.45 
70.83 

0.29 
2.87 

22.68 
25.66 

0.58 
0.62 

Murphy        
Swayne         .        .  ,     . 

63.23 
8G.36 

16.18 
9.79 

16  18 
1.04 

4.42 

2.8 

Here  it  will  be  seen  that  all  obstetricians  are  agreed  as  to  the 
immensely  greater  frequency  of  the  first  (o.L.A.)  position — the  only 
point  at  issue  being  the  relative  frequency  of  the  second  (O.D.A.)  and 
third  (O.D.P.). 

Various  explanations  have  been  given  of  the  greater  frequency  with 
which  the  head  lies  in  the  right  oblique  diameter.  By  some  it  is  re- 
ferred to  the  natural  tendency  of  the  back  of  the  foetus,  as  shown  by 
the  experimental  researches  of  Honing  and  other  writers,  to  be  directed, 
in  consequence  of  gravitation,  fprward  and  to  the  left  side  of  the 
mother  in  the  erect  attitude,  and  backward  and  to  her  right  side  in 
the  recumbent.  The  explanation  given  by  Simpson  was  that  the  head 
lay  in  the  right  oblique  diameter  in  consequence  of  the  measurement 
of  the  left  oblique  being  more  or  less  lessened  by  the  presence  of  the 
rectum.  When  the  rectum  is  collapsed,  indeed,  the  narrowing  of  the 
diameter  is  slight ;  but  it  is  so  often  distended  by  fecal  matter — some- 
times, when  constipation  exists,  to  a  very  great  extent — that  it  may 
readily  have  a  very  important  influence  in  determining  the  position  of 
the  fcetal  head. 

In  describing  the  mechanism  of  delivery,  it  will  be  well  for  us  to, 
concentrate  our  attention  on  the  first  (O.L.A.),  or  most  common,  posi- 
tion, dwelling  subsequently  more  briefly  on  the  differences  between  it 
and  the  less  common  ones. 

Description  of  the  First  Position. — In  this  position,  when  the 
head  commences  to  descend,  the  occiput  lies  in  the  brim  pointing  to 
the  left  ilio-pectineal  eminence,  the  forehead  is  directed  to  the  right 
sacro-iliac  synchondrosis,  and  the  sagittal  runs  obliquely  across  the 
pelvis  in  the  right  oblique  diameter.  The  back  of  the  child  is  turned 
toward  the  left  side  of  the  mother's  abdomen,  the  right  shoulder  to  her 

1  Leishman's  System  of  Midwifery,  p.  341. 


DELIVERY    IN    HEAD    PRESENTATIONS.  281 

right  side,  the  left  to  her  left  side  (Fig.  101).  If  a  vaginal  examination 
be  now  made  (the  patient  lying  in  the  ordinary  obstetric  position),  and 
the  os  be  sufficiently  open,  the  finger  will  impinge  upon  the  protuber- 
ance of  the  right  parietal  bone,  which  is  described  as  the  "  presenting 
part,"  a  term  which  has  received  various  definitions,  the  best  of  which 
is  probably  that  adopted  by  Tyler  Smith,  viz.,  "that  portion  of  the 
foatal  head  felt  most  prominently  within  the  circle  of  the  os  uteri,  the 
vagina,  and  the  ostium  vaginae,  in  the  successive  stages  of  labor."  If 
the  tip  of  the  examining  finger  be  passed  slightly  upward,  it  will  feel 
the  sagittal  suture  running  obliquely  across  the  pelvis,  and,  if  this  be 
traced  downward  and  to  the  left,  it  will  come  upon  the  triangular  poste- 
rior fontanelle,  with  the  lambdoidal  sutures  diverging  from  it.  If  the 


FIG.  101. 


Attitude  of  child  in  first  position  (O.L.A.).    (After  HODGE.) 

finger  could  be  passed  sufficiently  high  in  the  opposite  direction, 
upward  and  to  the  right,  it  would  come  upon  the  large  anterior  fonta- 
nelle ;  but  at  this  time  that  is  too  high  up  to  be  within  reach.  The 
chin  is  slightly  flexed  upon  the  sternum,  this  flexion,  as  we  shall 
presently  see,  being  greatly  increased  as  the  head  begins  to  descend. 

The  head,  at  the  commencement  of  labor,  generally  lies  within  the 
pelvic  brim,  especially  in  primiparae.  In  multiparae,  owing  to  the 
relaxation  of  the  abdominal  parietes,  the  uterus  is  apt  to  fall  somewhat 
forward,  and  the  head  consequently  is  more  entirely  above  the  brim, 
but  is  pushed  within  it  as  soon  as  labor  actually  commences. 

Naegele — and  his  description  has  been  adopted  by  most  subsequent 
writers — describes  the  head,  at  this  period,  as  lying  obliquely  in  rela- 
tion to  the  brim,  the  right  parietal  bone,  on  which  the  'examining  finger 
impinges,  being  supposed  by  him  to  be  much  lower  than  the  left.  The 
accuracy  of  this  view  has,  of  late  years,  been  contested,  and  it  is  now 
pretty  generally  admitted  that  this  obliquity  does  not  exist,  and  that 


282  LABOR. 

the  head  enters  the  brim  of  the  pelvis  with  both  parietal  bones  on  the 
same  level,  and  with  its  bi-parietal  diameter  parallel  to  the  plane  of 
the  inlet  (Fig.  102).  Naegele's  view  was  adopted,  partly  because  the 
finger  always  felt  the  right  parietal  protuberance  lowrest,  and  partly 
because  it  was  at  that  point  that  the  "  caput  succedaneum"  or  swelling 
observed  on  the  head  after  delivery,  was  always  formed.  Both  argu- 
ments are,  however,  fallacious  ;  for  the  right  parietal  bone  is  the  part 
which  would  naturally  be  felt  lowest,  on  account  of  the  oblique  posi- 
tion of  the  pelvis  to  the  trunk  ;  while,  with  regard  to  the  caput  suc- 
cedaneum, it  has  been  conclusively  proved  by  Duncan  that  it  does  not 
form  on  the  point  most  exposed  to  pressure,  as  Naegele  assumed,  but 
on  the  part  of  the  head  where  there  is  least  pressure — that  is,  the  part 
lying  over  the  axis  of  the  vaginal  canal. 


FIG.  102. 


First  position  (O.L.A.)  :  Movement  of  flexion. 

Division  of  Mechanical  Movements  into  Stages. — In  tracing 
the  progress  of  the  head  from  the  position  just  described,  obstetricians 
have  been  in  the  habit  of  dividing  the  movements  it  undergoes  into 
various  stages,  which  are  convenient  for  the  purpose  of  facilitating 
description.  It  must  be  borne  in  mind  that  these  are  not  evident  and 
distinct  stages,  which  can  always  be  made  out  in  practice,  but  that 
they  run  insensibly  into  one  another,  and  often  occur  simultaneously, 
or  nearly  so,  in  rapid  labor.  They  may  be  described  as  :  1 .  Flexion. 
2.  First  movement  of  descent.  3.  Levelling  or  adjusting  movement. 
4.  Rotation.  5.  Second  movement  of  descent  and  extension.  6.  External 
rotation. 

1.  Flexion.  The  first  movement  of  the  head  consists  of  a  rotation 
on  its  bi-parietal  diameter,  by  which  the  chin  of  the  child  becomes 
bent  on  the  sternum,  and  the  occiput  descends  lower  than  the  forehead. 
By  this  there  is  a  clear  gain  of  at  least  a  half-inch,  for  the  occipito- 
bregmatic  diameter  (3^  inches)  becomes  substituted  for  the  occipito- 
frontal  (4J  inches).  (Fig.  102.) 


DELIVERY    IN    HEAD    PRESENTATIONS.  283 

The  movement  is  most  marked  when  the  pelvis  is  narrow,  and  in 
some  cases  of  pelvic  deformity  it  takes  place  to  an  extreme  degree ; 
while,  in  unusually  large  and  roomy  pelves,  it  occurs  to  a  very  slight 
extent,  or  not  at  all.  The  reason  of  this  flexion  is  twofold.  Solayres 
and  the  majority  of  obstetricians  explain  it  by  saying  that  the  expul- 
sive force  is  communicated  to  the  head  through  the  vertebral  column, 
and  inasmuch  as  the  head  is  articulated  much  nearer  the  occiput  than 
the  sinciput,  the  resistance  being  equal,  the  former  must  be  pushed 
down.  This  is,  doubtless,  the  correct  explanation  of  the  flexion  after 
the  membranes  are  ruptured ;  but,  before  that  happens,  the  ovum  is 
practically  a  bag  of  water,  which  is  equally  compressed  at  all  points 
by  the  uterine  contraction,  and  is  pushed  downward  through  the  os 
en  masse,  the  expulsive  force  not  being  transmitted  through  the  ver- 
tebral column  at  all.  Under  such  circumstances  flexion  is  probably 
effected  in  the  following  way :  the  head  being  articulated  nearer  the 
occiput  than  the  forehead,  and  being  equally  pressed  upon  from  below 


FIG.  103. 


First  positionf1]  (O.L.A.)  :  Occiput  in  the  cavity  of  the  pelvis.    (After  HODGE.) 

by  the  resisting  structures,  the  pressure  is  more  effectual  on  the  fore- 
head— consequently  that  is  forced  upward,  and  the  occiput  descends. 
This  explanation  would  also  hold  good  after  the  rupture  of  the  mem- 
branes, and  probably  both  causes  assist  in  effecting  the  movement. 

2  and  3.  Descent  and  levelling  movement.  The  movements  of  descent 
and  levelling  may  be  described  together.  As  soon  as  the  head  is  liber- 
ated from  the  os  uteri,  it  descends  pretty  rapidly  through  the  pelvis, 
until  the  occiput  reaches  a  point  nearly  opposite  the  lower  part  of  the 
foramen  ovale  (Fig.  103),  and  the  sinciput  is  opposite  the  second  bone 
of  the  sacrum.  A  levelling  movement  now  occurs,  the  anterior  fonta- 
nelle  comes  to  be  more  easily  within  reach,  more  on  a  level  with  the 
posterior,  and  the  chin  is  no  longer  so  much  flexed  on  the  sternum. 
This  change  is  due  to  the  fact  that  the  anterior  end  of  the  ovoid 
experiences  greater  resistance  than  the  posterior,  and  as  soon  as  this 
resistance  counterbalances  and  exceeds  that  applied  to  the  latter,  the 
sinciput  must  descend.  The  right  side  of  the  head  also  descends  more 
than  the  left  from  a  similar  cause,  so  that  the  head  becomes,  as  it  were, 
slightly  flexed  on  the  right  shoulder.  This  obliquity  of  the  head  on 
its  transverse  diameter  in  the  lower  part  of  the  pelvis  has  been  denied 

[l  This  represents  the  second  position  (O.D.A.).— ED.! 


284  LABOR. 

by  Kiineke,1  who  maintains  that  the  head  passes  through  the  entire 
pelvis  in  the  same  position  as  it  enters  the  brim ;  that  sis,  with  both 
parietal  bones  on  a  level,  so  that  the  point  of  intersection  of  the  trans- 
verse and  antero-posterior  diameters  of  the  pelvis  would  correspond 
with  the  sagittal  suture.  There  is,  however,  good  reason  to  believe 
that  in  the  lower  half  of  the  pelvic  cavity  the  head  is  not  truly 
synclitic,  as  Kiineke  describes,  but  that  the  right  parietal  bone  is  on 
a  somewhat  lower  level  than  the  left. 

4.  Rotation.  The  movement  of  rotation  is  very  important.  By  it 
the  long  diameter  of  the  head  is  changed  from  the  oblique  diameter 
of  the  pelvic  cavity  to  the  antero-posterior  diameter  of  the  outlet 
(Fig.  104),  or  to  a  diameter  nearly  corresponding  to  it,  so  that  the 


FIG  104. 


First  position  (O.L.A.)  :  Occiput  at  outlet  of  the  pelvis.    (After  HODGE.) 

long  diameter  of  the  head  is  brought  into  relation  with  the  longest 
diameter  of  the  pelvic  outlet.  This  alteration  almost  always  takes 
place,  and  may  be  readily  observed  by  the  accoucheur  who  carefully 
watches  the  progress  of  labor.  Various  explanations  have  been  given 
of  its  causes.  The  one  most  generally  adopted  is,  that  it  is  due  to  the 
projection  inward  of  the  ischial  spines,  which  narrow  the  transverse 
diameter  of  the  pelvic  outlet.  As  the  pains  force  the  occiput  down- 
ward, its  rotation  backward  is  prevented  by  the  projection  of  the  left 
ischial  spine,  while  its  rotation  forward  is  favored  by  the  smooth 
bevelled  surface  of  the  ascending  ramus  of  the  ischium.  Similarly 
the  ischial  spine  on  the  opposite  side  prevents  the  rotation  forward  of 
the  forehead,  which  is  guided  backward  to  the  cavity  of  the  sacrum 
by  the  smooth  surface  of  the  sacro-ischiatic  ligaments.  These  arrange- 
ments, therefore,  give  a  screw-like  form  to  the  interior  of  the  pelvis ; 
and  as  the  pains  force  the  head  downward  they  are  effectual  in  im- 
parting to  it  the  rotatory  movement  which  is  of  such  importance  in 
adapting  it  to  the  longest  measurement  of  the  outlet. 

By  most  of  the  German  obstetricians  the  influence  of  the  ischial 
spines  and  of  the  smooth  pelvic  planes  in  producing  rotation  is  not 
admitted.  They  rather  refer  the  change  of  direction  to  the  increased 
resistance  the  head  meets  from  the  posterior  wall  of  the  pelvis,  and 
from  the  perineal  structures.  Whichever  part  of  the  head  first  meets 
this  resistance,  which  is  much  greater  than  that  of  the  anterior  part  of 
the  pelvis,  must  necessarily  be  pressed  forward ;  and  as,  in  the  large 

1  Die  vier  Factoren  der  Geburt,  Berlin,  1869. 


DELIVERY    IN    HEAD    PRESENTATIONS.  285 

majority  of  cases,  the  posterior  fontanelle  descends  first,  it  is  thus 
pressed  forward  until  rotation  is  effected.  This  view  has  the  advan- 
tage of  accounting  equally  well  for  the  rotation  in  occipito-posterior 
as  in  occipito-anterior  positions,  the  former  of  which,  on  the  more 
ordinarily  received  theory,  are  not  quite  satisfactorily  explicable.  It 
does  not  follow  that  the  smooth  surfaces  of  the  pelvic  planes  are 
without  influence  in  favoring  the  rotation.  On  the  contrary,  they 
doubtless  greatly  facilitate  it ;  and  it  is  probable  that  both  these 
agencies  operate  in  producing  anterior  rotation  of  the  occiput. 

In  some  rare  cases  the  head  escapes  rotation  and  reaches  the  perineum 
still  lying  in  the  oblique  diameter.  Even  here,  however,  rotation  is 
generally  effected,  often  suddenly,  just  as  the  head  is  about  to  pass  the 
vulva,  and  it  is  very  rarely  expelled  in  the  oblique  position.  The 
movement  at  this  stage  may  be  explained  by  the  perineum,  which  is 
attached  at  its  sides,  and  grooved  in  its  centre;  to  the  hollow  so  formed 
the  long  diameter  of  the  head  accommodates  itself,  and  is  thus  rotated 
into  the  autero-posterior  diameter  of  the  outlet. 

5.  Extension.  By  the  process  just  described  the  face  is  turned  back 
into  the  hollow  of  the  sacrum ;  but  the  head  does  not  lie  absolutely  in 
the  autero-posterior  diameter  of  the  pelvic  outlet,  but  rather  in  one 
between  it  and  the  oblique.  The  occiput  is  still  forced  down  by  the 
pains,  and,  in  consequence  of  its  altered  position,  is  enabled  to  pass 
between  the  rami  of  the  pubis,  and  advances  until  its  further  descent 
is  checked  by  the  nape  of  the  neck,  which  is  pressed  under  and  against 
the  arch  of  the  pubes.  By  this  means  the  occiput  is  fixed,  and,  the 
pains  continuing,  the  uterine  force  no  longer  acts  on  the  occiput,  but 
on  the  anterior  part  of  the  head,  which  is  now  pushed  down  and 


FIG.  105. 


First  position  (O.L.A.)  :  head  delivered.    (After  HODGE.) 

separated  from  the  sternum.  This  constitutes  extension.  As  the  head 
descends,  the  soft  structures  of  the  perineum  are  stretched,  and  the 
coccyx  pushed  back  so  as  to  enlarge  the  outlet.  The  pains  continue  to 
distend  the  perineum  more  and  more,  the  head  advancing  and  receding 
witli  each  pain.  As  the  forehead  descends,  the  sub-occipito-bregmatic, 
the  sub-occipito-frontal,  and  the  sub-occipito-mental  diameters  succes- 
sively present ;  the  occiput  turns  more  and  more  upward  in  front  of 
the  pubes  (Fig.  105),  and,  at  last,  the  face  sweeps  over  the  perineum 
and  is  born. 

The  mechanical  cause  of  this  movement  may  be  readily  explained. 


286 


LABOR. 


As  soon  as  the  occiput  has  passed  under  the  arch  of  the  pubes,  and  is 
no  longer  resisted  by  the  anterior  pelvic  walls,  the  head  is  subjected  to 
the  action  of  two  forces  :  that  of  the  uterine  pressure  acting  downward 
and  backward ;  and  that  of  the  resistance  of  the  posterior  walls  of  the 
pelvis  and  the  soft  parts  acting  almost  directly  forward.  The  necessary 
result  is  that  the  head  is  pushed  in  a  direction  intermediate  between 
these  two  opposing  forces — that  is,  downward  and  forward  in  the  axis 
of  the  pelvic  outlet. 

In  addition  to  the  slight  obliquity  which  exists  as  regards  the  direct 
relation  of  the  long  diameter  of  the  head  to  the  antero-posterior 
diameter  of  the  outlet  at  the  moment  of  its  expulsion,  the  head  also  lies 
somewhat  obliquely  in  relation  to  its  own  transverse  diameter,  so  that,  in 
the  majority  of  cases,  the  right  parietal  bone  is  expelled  before  the  left. 

6.  External  rotation.  Shortly  after  the  head  is  expelled,  as  soon  as 
renewed  uterine  action  commences,  it  may  be  observed  to  make  a 
distinct  rotatory  movement,  the  occiput  turning  to  the  left  thigh  of  the 


FIG.  106. 


External  rotation  of  bead  in  first  position  (O.L.A.).  -  (After  HODGE.) 

mother,  and  the  face  turning  upward  to  the  right  thigh  (Fig.  106). 
The  reason  of  this  is  evident.  When  the  head  descends  in  the  right 
oblique  diameter  the  shoulders  lie  in  the  opposite  or  left  oblique 
diameter,  and,  as  the  head  rotates  into  the  autero-posterior  diameter, 
they  are  necessarily  placed  more  nearly  in  the  transverse.  As  soon  as 
the  head  is  expelled  the  shoulders  are  subjected  to  the  same  uterine 
force  and  pelvic  resistance  as  the  head  has  just  been,  and  they  are. acted 
on  in  precisely  the  same  way.  Consequently  they  too  rotate,  but  in 
the  opposite  direction,  into  the  antero-posterior  diameter  of  the  outlet, 
or  nearly  so,  just  as  the  head  did,  and  as  they  do  so  they  necessarily 
carry  the  head  with  them,  and  cause  its  external  rotation. 

The  two  shoulders  are  soon  expelled,  the  left  shoulder  generally  the 
first,  sweeping  over  the  perineum  in  the  same  manner  as  the  face. 
This  is,  however,  not  always  the  case,  and  they  are  often  expelled 
simultaneously,  or  the  right  shoulder  may  come  first.  The  body  soon 
follows,  and  the  second  stage  of  labor  is  completed. 


DELIVERY    IN    HEAD    PRESENTATIONS.  287 

Second  Position. — In  the  second  position  (O.D.A.)  the  long  diam- 
eter of  the  head  lies  in  the  left  oblique  diameter  of  the  pelvis.  On 
making  a  vaginal  examination,  in  the  ordinary  obstetric  position,  the 
finger,  passing  upward  and  to  the  right,  feels  the  small  posterior  fonta- 
nelle ;  downward  and  to  the  left,  it  feels  the  anterior.  The  sagittal 
suture  lies  obliquely  across  the  pelvis  in  the  left  oblique  diameter. 
The  description  of  the  mechanism  of  delivery  is  precisely  the  same  as 
in  the  first  position  (O.L.A.),  substituting  the  word  left  for  right.  Thus 
the  finger  impinges  on  the  left  parietal  bone,  the  occiput  turns  from 
right  to  left  during  rotation.  After  the  birth  of  the  head  the  occiput 
turns  to  the  right  thigh  of  the  mother,  the  face  to  the  left  thigh. 

Third,  or  Right  Occipito-sacro-iliac  Position. — In  the  third  posi- 
tion (o.  D.  P.)  the  head  enters  the  pelvic  brim  with  the  occiput  directed 
backward  to  the  right  sacro-iliac  synchondrosis,  and  the  sinciput  for- 
ward to  the  left  foramen  ovale  (Fig.  107).  The  posterior  foutanelle  is 


FIG.  107. 


Third  position  (O.D.P.)  of  occiput  at  brim  of  pelvis. 


directed  backward,  the  anterior  fontanelle  forward,  while  the  examin- 
ing finger  impinges  on  the  left  parietal  bone.  The  mechanism  of 
delivery  in  these  cases  is  of  much  interest.  In  the  large  majority  of 
cases,  during  the  progress  of  delivery  the  occiput  rotates  forward  along 
the  right  side  of  the  pelvis,  until  it  comes  to  lie  almost  in  the  antero- 
posterior  diameter  of  the  outlet,  and  passes  under  the  pubic  arch,  the 
forehead  passing  over  the  perineum.  It  will  be  seen  that  during  part 
of  this  extensive  rotation  the  head  must  lie  in  the  second  position 
(O.D.A.),  and  the  case  terminates  just  as  if  it  had  been  in  the  second 
position  (O.D.A.)  from  the  commencement  of  labor. 

Manner  in  which  the  Occiput  is  Rotated  Forward. — How  is  it 
that  this  rotation  is  effected,  and  that  the  sinciput,  occupying  the  posi- 
tion of  the  occiput  in  the  first  position  (O.L.A.),  should  not  be  rotated 
forward  to  the  pubes  as  that  is  ?  This,  no  doubt,  may  be  explained  by 
the  fact  that  the  uterine  force  transmitted  through  the  vertebral  column 


288  LABOR. 

causes  the  occiput  to  descend  lower  than  the  sinciput,  so  that  in  most 
cases,  in  making  a  vaginal  examination,  the  posterior  fontanelle  can  be 
readily  felt,  while  the  anterior  is  high  up  and  out  of  reach.  The  head 
is,  therefore,  extremely  flexed,  and  so  descends  into  the  pelvic  cavity, 
until  the  occiput,  being  now  below  the  right  ischial  spine,  experiences 
the  resistance  of  the  pelvic  floor,  opposite  the  right  sacro-ischiatic  liga- 
ment, by  which  it  is  directed  forward.  The  forehead  is,  at  this  time, 
supposing  flexion  to  be  marked,  too  high  to  be  influenced  by  the 
anterior  pelvic  plane.  Pressure  continuing,  the  occiput  rotates  for- 
ward, the  forehead  passes  around  the  left  side  of  the  pelvis,  and  labor 
is  terminated  as  in  the  second  position  (O.D.A.). 

The  period  of  labor  at  which  rotation  takes  place  varies.  In  the 
majority  of  cases  it  does  not  occur  until  the  head  is  on  the  floor  of  the 
pelvis,  for  it  is  then  that  resistance  is  most  felt ;  but  the  greater  the 
resistance,  the  sooner  will  rotation  be  produced.  Hence  it  is  more 
likely  to  occur  early,  when  the  head  is  large  and  the  pelvis  compara- 
tively small. 

The  facility  with  which  this  movement  is  effected  obviously  depends 
upon  the  complete  flexion  of  the  chin  on  the  sternum,  by  which  the 
anterior  fontanelle  is  so  elevated  that  its  rotation  backward  is  not  resisted 
by  the  inward  projection  of  the  left  ischial  spine,  and  the  occiput  is 
correspondingly  depressed.  If,  however,  this  flexion  is  not  complete, 
and  the  anterior  fontanelle  is  so  low  as  to  be  readily  within  reach  of 
the  finger,  considerable  difficulty  is  likely  to  be  experienced.  In  many 
such  cases  rotation  is  still  eventually  effected,  but  in  others  it  is  not ;  and 
the  labor  is  then  terminated  with  the  face  to  the  pubes,  but  at  the  ex- 
pense of  considerable  delay  and  difficulty.  According  to  Dr.  Uvedale 
West,  of  Alford,  who  devoted  much  careful  study  to  the  subject,  this 
termination  occurs  in  about  4  per  cent,  of  occipito-posterior  positions. 
When  it  is  about  to  happen  the  anterior  fontanelle  may  be  felt  very 
low  down,  and  sometimes  even  the  forehead  and  superciliary  ridges. 
The  uterine  force  pushes  down  the  occiput,  the  sinciput  being  fixed 
behind  the  pubes,  which  it  obviously  cannot  pass  under,  as  does  the 
occiput  in  the  first  position.  The  sinciput,  therefore,  becomes  more 
flexed  and  pushed  upward,  while  the  resistance  of  the  pelvic  floor 
directs  the  occiput  forward.  The  perineum  now  becomes  enormously 
distended  by  the  back  part  of  the  head,  and  is  in  great  danger  of 
laceration.  The  occiput  is  eventually,  but  not  without  much  difficulty, 
.expelled.  A  process  of  extension  now  occurs,  the  nape  of  the  neck 
being  fixed,  as  it  were,  against  the  centre  of  the  perineum,  the  expel- 
ling force  now  acting  on  the  forehead,  and  producing  rotation  of  the 
head  on  its  transverse  axis.  The  forehead  and  face  are  thus  protruded, 
and  the  body  follows  without  difficulty. 

It  is  said  that,  in  a  few  exceptional  cases,  where  the  anterior  fontanelle 
is  much  depressed,  the  labor  may  terminate  by  the  conversion  of  the 
presentation  into  one  of  the  face,  the  head  rotating  on  its  transverse 
axis,  the  forehead  passing  to  the  posterior  part  of  the  pelvis,  and  the 
chin  emerging  under  the  pubes.  It  is  obvious,  however,  that  this 
change  can  only  occur  when  the  head  is  unusually  small,  and  it  must 
of  necessity  be  extremely  rare. 


DELIVERY    IN    HEAD    PRESENTATIONS.  289 

Reference  has  already  been  made  to  Naegele's  views  as  to  the  rarity 
of  the  second  position  (O.D.A.),  and  to  his  opinion  that  cases  in  which 
the  occiput  was  found  to  point  to  the  right  foramen  ovale  were  only 
transitional  stages  in  the  rotation  of  occipito-posterior  positions.  Such 
an  assumption,  however,  is  unwarrantable,  unless  the  case  has  been 
watched  from  the  very  commencement  of  labor.  Many  perfectly 
qualified  observers  have  arrived  at  the  conclusion  that  second  posi- 
tions (O.D.A.)  are  far  more  common  than  Naegele  supposed ;  and  in 
the  table  already  quoted  (page  280)  it  will  be  seen  that  while  Murphy 
estimates  the  second  (O.D.A.)  and  third  (O.D.P.)  as  being  equally  fre- 
quent, Swayne  believes  the  second  (O.D.A.)  to  be  much  more  common 
than  the  third  (O.D.P.).  It  is  probable  that  the  weight  of  Naegele's 
authority  has  induced  many  observers  to  classify  second  (O.D.A.)  posi- 
tions as  third  (O.D.P.)  positions  in  which  partial  rotation  has  already 
been  accomplished.  My  own  experience  would  certainly  lead  me  to 
think  that  second  (O.D.A.)  positions  are  very  far  from  uncommon.  The 
question,  however,  must  be  considered  to  be  in  abeyance,  until  further 
observations  by  competent  authorities  enable  us  to  decide  it  conclu- 
sively. 

Fourth,  or  Left  Occipito-sacro-iliac  Position. — The  fourth  posi- 
tion (O.L.P.)  is  just  as  much  the  reverse  of  the  second  as  the  third  is  of 
the  first.  The  occiput  points  to  the  left  (Fig.  108)  sacro-iliac  syn- 
chondrosis,  and  the  finger  impinges  on  the  right  parietal  bone.  The 
mechanism  is  precisely  the  same  as  in  the  third  position  (O.D.P.),  the 
rotation  taking  place  from  left  to  right. 


Fourth  position  (O.L.P.)  of  occiput  at  pelvic  brim. 

Formation  of  the  Caput  Succedaneum. — The  formation  of  the 
caput  succedaneum  has  been  already  alluded  to.  This  term  is  applied 
to  the  cedematous  swelling  which  forms  on  the  head,  and  is  produced 
by  effusion  from  the  obstruction  of  the  venous  circulation  caused  by 
the  pressure  to  which  the  head  is  subjected.  It  follows  that  the  size 
of  the  swelling  is  in  direct  proportion  to  the  length  of  the  labor.  In 
rapid  deliveries,  in  which  the  head  is  forced  through  the  pelvis  quickly, 
it  is  scarcely,  if  at  all,  developed ;  while  after  protracted  labor  it  is 
large  and  distinct,  and  may  obscure  the  diagnosis  of  the  position,  by 

19 


290 

preventing  the  sutures  and  fontanelles  being  feit.  Its  situation  varies 
according  to  the  position  of  the  head :  thus,  in  the  first  (O.L.A.)  and 
fourth  (O.L.P.)  positions  it  forms  on  the  right  parietal  bone,  in  the 
second  (O.D.A.)  and  third  (O.D.P.)  on  the  left ;  and  we  may  therefore 
verify,  by  inspection  of  its  site,  the  accuracy  of  our  diagnosis. 

An  ordinary  mistake  which  has  been  made  by  obstetricians  is  to 
regard  the  caput  succedaneum  as  formed  at  the  point  where  the  head 
has  been  most  subjected  to  pressure ;  while,  in  fact,  it  forms  on  that 
part  which  is  most  unsupported  by  the  maternal  structures,  and  where 
the  swelling  may  consequently  most  readily  occur.  Therefore,  in  the 
early  stages  of  the  labor,  it  always  forms  on  the  part  of  the  Lead  which 
lies  in  the  circle  of  the  os  uteri ;  while  in  subsequent  stages,  it  forms 
on  that  which  lies  in  the  axis  of  the  vaginal  canal,  and  eventually  is 
most  prominent  on  the  part  that  is  first  expelled  from  the  vulva. 

Alteration  in  the  Shape  of  the  Head  from  Moulding1. — A  few 
words  may  be  said  as  to  the  alteration  in  the  form  of  the  foetal  head 
which  occurs  in  tedious  labors,  and  results  from  the  moulding  which 
it  has  undergone  in  its  passage  through  the  pelvis.  The  smaller  the 
pelvis,  and  the  greater  the  pressure  applied  to  the  head  during  delivery, 
the  more  marked  this  is.  The  result  is,  that  in  vertex  presentations 
the  occipito-mental  and  occipito-frontal  diameters  are  elongated  to  the 
extent  of  an  inch,  or  even  more,  while  the  transverse  diameters  are 
lessened,  from  compression  of  the  parietal  bones.  This  moulding  is 
of  unquestionable  value  in  facilitating  the  birth  of  the  child.  The 
amount  of  apparent  deformity  is  very  considerable,  and  may  even  give 
rise  to  some  anxiety.  It  is  well  to  remember,  therefore,  that  it  is 
always  transient,  and  that  in  a  few  hours,  or  days  at  most,  the  elas- 
ticity of  the  soft  cranial  bones  causes  them  to  resume  their  natural 
form.  The  caput  succedaneum  also  disappears  rapidly  ;  therefore  no 
amount  of  deformity  from  either  of  these  causes  need  give  rise  to 
anxiety,  or  call  for  any  treatment. 


CHAPTER    III. 

MANAGEMENT  OF  NATURAL  LABOR. 

ALTHOUGH  labor  is  a  strictly  physiological  function,  and  in  a  large 
majority  of  cases  might,  no  doubt,  be  safely  accomplished  without 
assistance  from  the  accoucheur,  still  medical  aid,  properly  given,  is 
always  of  value  in  facilitating  the  process,  and  is  often  absolutely 
essential  for  the  safety  of  the  mother  and  child. 

Preparatory  Treatment. — The  management  of  the  pregnant  woman 
before  delivery  is  a  point  which  should  always  receive  the  attention  of 
the  medical  attendant,  since  it  is  of  consequence  that  the  labor  should 
come  on  when  she  is  in  as  good  a  state  of  health  as  possible.  For  this 


MANAGEMENT  OF  NATURAL  LABOR.         291 

purpose  ordinary  hygienic  precautions  should  never  be  neglected  in 
the,  latter  months  of  gestation.  The  patient  should  take  regular  and 
gentle  exercise,  short  of  fatigue,  and  if  the  weather  permit,  should 
spend  as  much  of  her  time  as  possible  in  the  open  air.  Hot  rooms, 
late  hours,  and  excitement  of  all  kinds  should  be  strictly  avoided. 
The  diet  should  be  simple,  nutritious,  and  unstimulating.  The  state 
of  the  bowels  should  be  particularly  attended  to.  During  the  few 
days  preceding  labor  the  descent  of  the  uterus  often  causes  pressure  on 
the  rectum,  and  prevents  its  evacuation.  Hence  it  is  customary  to 
prescribe  occasional  gentle  aperients,  such  as  small  doses  of  castor  oil, 
for  a  few  days  before  the  expected  period  of  delivery.  Some  caution, 
however,  is  necessary,  as  it  is  certainly  not  very  uncommon  for  labor  to- 
be  determined  rather  sooner  than  was  anticipated,  in  consequence  of 
the  irritation  of  too  large  a  purgative  dose.  The  state  of  the  bowels 
should  always  be  inquired  into  at  the  commencement  of  labor,  and,  if 
there  be  any  reason  to  suspect  that  they  are  loaded,  a  copious  enema 
should  be  administered.  This  is  always  a  proper  precaution  to  take, 
for  a  loaded  rectum  is  a  common  cause  of  irregular  and  ineffective 
uterine  action  ;  and  even  when  it  does  not  produce  this  result,  the  escape 
of  the  feces,  in  consequence  of  pressure  on  the  bowel  during  the  propul- 
sive stage,  is  always  disagreeable  both  to  patient  and  practitioner. 

The  dress  of  the  patient  during  pregnancy  may  be  here  adverted 
to;  for  much  discomfort  may  arise,  and  the  satisfactory  progress  of 
labor  may  even  be  interfered  with,  from  errors  in  this  respect. 

After  the  uterus  has  risen  out  of  the  pelvis  the  ordinary  corset  which 
most  women  wear  is  apt  to  produce  very  injurious  pressure;  still  more 
so  when  attempts  are  made  to  conceal  the  increased  size  by  tight  lacing. 
After  the  fourth  or  fifth  month,  therefore,  the  comfort  of  the  patient 
is  much  increased  by  wearing  a  specially  constructed  pair  of  stays  with 
elastic  let  into  the  sides  and  front,  so  that  they  accommodate  them- 
selves to  the  gradual  increase  of  the  figure.  Such  are  made  by  all 
stay-makers,  and  should  be  worn  whenever  the  circumstances  of  the 
patient  permit.  Failing  this,  it  is  better  to  avoid  the  use  of  the  corset 
altogether,  and  to  have  as  little  pressure  on  the  uterus  as  possible  ; 
although  many  women  cannot  do  without  the  support  to  which  they 
are  accustomed.  To  multipart,  especially  if  there  be  much  laxity  of 
the  abdominal  parietes,  a  well-fitting  elastic  abdominal  belt  is  often  a 
great  comfort.  This  is  constructed  so  that  it  can  be  tightened  when 
the  patient  is  walking  and  in  the  erect  position,  when  such  support 
is  most  required,  and  readily  loosened  when  desired. 

Necessity  of  Attending  to  the  First  Summons. — It  is  hardly 
necessary  to  insist  on  the  necessity  of  the  practitioner  attending  imme- 
diately to  the  first  summons  to  the  patient.  It  is  true  that  he  may 
very  often  be  sent  for  long  before  he  is  actually  required.  But,  on  the 
other  hand,  it  is  quite  impossible  to  foresee  what  may  be  the  state  of 
any  individual  case.  By  prompt  attention  he  may  be  able  to  rectify  a 
malposition,  or  prevent  some  impending  catastrophe,  and  thus  save  his 
patient  from  consequences  of  the  utmost  gravity. 

The  practitioner  should  always  be  provided  with  the  articles  which 
he  may  require.  The  ordinary  obstetric  cases,  containing  one  or  two 


292  LABOR. 

bottles  and  a  catheter,  such  as  are  sold  by  most  instrument-makers,  are 
cumbrous  and  useless;  while  "obstetric  bags"  are  expensive  luxuries 
not  within  the  reach  of  all.  Everyone  can  manufacture  an  excellent 
obstetric  bag  for  himself,  at  a  small  expense,  by  having  compartments 
for  holding  bottles  stitched  on  to  the  sides  of  an  ordinary  leather  bag, 
such  as  is  sold  for  a  few  shillings  at  any  portmanteau-maker's.  It  is 
a  great  comfort  to  haye  at  hand  all  that  may  be  required,  and  the  bag 
should  contain  chloroform  or  other  anaesthetic,  antiseptics  in  a  con- 
centrated form,1  chloral,  laudanum,  the  liquor  ferri  perchloridi  of  the 
Pharmacopoeia,  the  liquid  extract  of  ergot,  and  a  hypodermatic  syringe, 
with  bottles  containing  carbolized  oil,  ether,  and  a  solution  of  ergotine 
for  subcutaneous  injection.  If  it  also  contain  a  Higginson's  syringe, 
a  small  elastic  catheter,  a  good  pair  of  forceps,  and  one  or  two  suture 
needles,  with  some  silver  wire  or  chromic  gut,  the  practitioner  is  pro- 
vided against  any  ordinary  contingency.  Other  articles  that  may  be 
required,  such  as  thread,  scissors,  and  the  like,  are  generally  provided 
by  the  nurse  or  patient. 

Duties  on  First  Visiting-  the  Patient. — On  arriving  at  the  house 
the  practitioner  should  have  his  visit  announced  to  the  patient,  and  he 
will  very  often  find  that  the  first  effect  of  his  presence  is  to  arrest  the 
pains  that  have  been  hitherto  progressing  rapidly ;  thereby  affording  a 
very  conclusive  proof  of  the  influence  of  mental  impressions  on  the 
progress  of  labor.  If  the  pains  be  not  already  propulsive,  it  is  well 
that  he  should  occupy  himself  at  first  in  general  inquiries  from  the 
attendants  as  to  the  progress  of  the  labor,  and  in  seeing  that  all  the 
necessary  arrangements  are  satisfactorily  carried  out,  so  as  to  allow  the 
patient  time  to  get  accustomed  to  his  presence.  If  he  have  any  choice 
in  the  matter,  he  should  endeavor  to  secure  a  large,  airy,  and  well- 
ventilated  apartment  for  the  lying-iu  room,  as  far  removed  as  possible 
from  without.  He  may  also  see  to  the  bed,  which  should  be  without 
curtains,  and  prepared  for  the  labor  by  having  a  waterproof  sheeting 
laid  under  a  folded  blanket  or  sheet,  on  which  the  patient  lies.  These 
receive  the  discharges  during  labor,  and  can  be  pulled  from  under  the 
patient  after  delivery,  so  as  to  leave  the  dry  clothes  beneath.  Among 
the  lower  classes,  the  lying-in  chamber  is  considered  a  legitimate  meet- 
ing-place for  numerous  female  friends  to  gossip,  whose  conversation  is 
often  distressing,  and  is  certainly  injurious,  to  a  woman  in  the  excitable 
condition  associated  with  labor.  The  medical  attendant  should,  there- 
fore, insist  on  as  much  quiet  as  possible,  and  should  allow  no  one  in  the 
room  except  the  nurse  and  some  one  friend  whose  presence  the  patient 
may  desire.  The  husband's  presence  must  be  left  to  the  wishes  of  the 
patient.  Some  women  like  their  husbands  to  be  with  them,  while 
others  prefer  to  be  without  them,  and  the  medical  attendant  is  bound 
to  act  in  accordance  with  the  patient's  desire. 

Antiseptic  Precautions. — Here  it  is  necessary  to  describe  the  anti- 
septic precautions  which  should  be  adopted  in  the  practice  of  modern 

1  Dr.  Cullingworth  recommends  a  very  handy  form  in  which  these  can  be  carried.  He  has  a 
box  of  powders  prepared,  each  of  which  contains  10  grains  of  corrosive  sublimate,  50  of  tartaric 
acid,  and  1  of  cochineal.  One  of  these,  dissolved  in  a  pint  of  water,  makes  a  1  :  1000  solution  of 
the  perchloride  of  mercury.— Brit.  Med.  Journ.,  October  6,  1S88. 


MANAGEMENT  OF  NATURAL  LABOR.         293 

midwifery.  The  marvellous  results  which  have  followed  the  intro- 
duction of  antiseptic  midwifery  into  lying-in  hospitals  in  all  parts  of 
the  world,  and  which  have  converted  these  institutions  from  hotbeds 
of  disease  into  safer  places  for  delivery  than  the  most  luxurious  homes, 
form  one  of  the  most  striking  chapters  in  the  history  of  modern  medi- 
cine. These  will  call  for  more  detailed  notice  when  we  come  to  treat 
of  puerperal  septicaemia.  Here  it  will  suffice  to  state  that  by  universal 
consent  it  is  now  recognized  as  essential  that  similar  care  should  be 
taken  in  private  practice,  and  the  more  scrupulous  the  practitioner  is, 
the  less  will  be  the  mortality  and  morbidity  he  has  to  deal  with  among 
his  patients.  Every  practitioner  \vho  is  old  enough  to  have  practised 
before  antiseptics  were  used,  and  who  has  rigorously  employed  them 
of  late  years,  will  gratefully  recognize  the  comparative  comfort  of  his 
present  work.  The  relief  from  the  haunting  dread  of  septic  infection, 
which  was  one  of  the  bugbears  of  practice  in  days  gone  by,  is  of  itself 
an  unspeakable  boon.  It  cannot,  therefore,  be  too  strongly  insisted 
on  that  minute  care  in  this  respect  should  be  taken,  both  as  regards 
the  practitioner  and  the  nurse,  on  whom  the  subsequent  care  of  the 
patient  devolves. 

Strict  asepsis  in  midwifery  is,  of  course,  impossible ;  but  absolute 
cleanliness  in  connection  with  labor,  along  with  the  free  use  of  suitable 
disinfectants,  will  reduce  to  a  minimum  the  risk  of  infection  by  germs 
from  without.  The  first  thing  to  be  done  before  making  a  vaginal 
examination  is  thoroughly  to  scrub  the  hands  with  soap  and  water, 
and  the  nails  with  a  hard  brush.  This  should  be  insisted  on  as  regards 
the  nurse  also.  A  basin  containing  a  1  : 1000  solution  of  perchloride 
of  mercury  should  be  placed  by  the  side  of  the  bed,  and  the  hands 
should  be  thoroughly  washed  in  the  fluid  before  making  a  vaginal 
examination.  This  ablution  should  be  repeated  frequently  during  the 
course  of  the  labor.  It  has  been  conclusively  shown  that  no  other 
antiseptic  is  so  reliable,1  and  no  other  should  be  used  for  the  hands. 
Instead  of  using  ordinary  lard  or  cold  cream  for  lubricating  the  exam- 
ining finger,  the  practitioner  should  carry  in  his  bag  for  this  purpose 
some  disinfecting  unguent,  such  as  carbolized  or  eucalyptus  vaseline. 
As  soon  as  labor.is  established  the  vulva  should  be  thoroughly  washed 
with  soap  and  water,  and  then  wetted  with  the  1  :  1000  solution  and 
for  this  purpose  cotton-wool  soaked  in  the  solution  should  be  used. 
Sponges,  so  generally  employed  in  labor,  should  be  banished  from  the 
lying-in  room,  since  it  is  practically  impossible  to  keep  them  perfectly 
clean. 

The  use  of  antiseptic  injections  before,  during,  and  after  labor  is 
a  point  on  which  there  is  a  considerable  divergence  of  opinion.  Many 
object  to  them  altogether  as  necessitating  unnecessary  manipulations, 
which  may  tend  to  the  introduction  of  infective  germs  rather  than  to 
their  destruction.  Frequent  douching  during  labor  is  certainly  alto- 
gether needless,  and  has  the  drawback  of  washing  away  the  lubricating 
mucous  secretion  of  the  vagina.  I  am  myself  in  the  habit  of  ordering 
a  single  vaginal  injection  of  1  :  1000  at  the  commencement  of  labor, 

1  See  Boxall  on  "  Fever  in  Childbed,"  Obst.  Trans.,  vol.  xxxii.  p.  224. 


294  LABOR. 

and  no  more,  and  to  this  there  can  be  no  reasonable  objection.  The 
use  of  an  occasional  warm  irrigation  after  labor  has  always  seemed  to 
me  to  increase  the  comfort  of  the  patient ;  but  this  rather  comes  to  be 
considered  under  the  head  of  puerperal  convalescence. 

Attention  to  Cleanliness. — The  most  scrupulous  care  as  to  the 
cleanliness  of  the  lying-in  room  and  its  furniture  is  an  important 
point  to  consider.  The  sheets  and  linen  should  be  clean  and  fre- 
quently changed,  and  sanitary  towels  should  be  used  to  receive  the 
discharges  instead  of  napkins,  which  are  apt  to  be  imperfectly  cleansed. 
These  are  points  which  chiefly  concern  the  nurse,  but  which  it  is  the 
duty  of  the  practitioner  to  supervise.  It  is  most  important  that  the 
nurse  should  have  thoroughly  impressed  on  her  the  necessity  of  the 
antiseptic  precautions  we  are  discussing,  since  she  is  in  contact  with 
the  genitals  of  the  patient  many  times  daily,  and  for  many  days  in 
succession,  while  the  duties  of  the  medical  attendant  in  this  respect 
are  generally  at  an  end  when  the  labor  is  over. 

Vaginal  Examination. — If  pains  be  actually  present  a  vaginal  ex- 
amination is  essential,  and  should  not  be  delayed.  It  enables  us  to 
ascertain  whether  the  labor  has  commenced  or  not,  and  whether  the 
presentation  is  natural  or  otherwise.  The  pains,  although  apparently 
severe,  may  be  altogether  spurious,  and  labor  may  not  have  actually 
commenced.  It  is  of  much  importance,  both  for  our  own  credit  and 
comfort,  that  we  should  be  able  to  diagnose  the  true  character  of  the 
pains ;  for  if  they  be  so-called  "  false  "  pains,  we  might  wait  hours  in 
fruitless  expectation  of  progress,  while  delivery  is  still  far  off.  The 
necessity  of  ascertaining,  therefore,  the  actual  state  of  affairs  need  not 
further  be  insisted  on.  [We  would,  in  this  connection,  particularly 
recommend  to  accoucheurs  the  caoutchouc  dam  and  apron  devised  as  a 
protector  and  conduit  by  Prof.  Howard  A.  Kelly,  of  Baltimore,  as  it 
not  only  prevents  the  soiling  of  the  bed  and  the  undergarments  of  the 
patient,  but  will  admit  of  a  reliable  measurement  of  the  amniotic  fluid 
when  in  excess,  and  of  that  removed  from  the  head  by  tapping  in 
hydrocephalus.  It  has  been  found  specially  useful  in  cases  of  emer- 
gency and  in  practice  among  the  poor  and  unprepared. — ED.] 

False  pains  are  chiefly  characterized  by  their  irregularity,  some- 
times coming  on  at  short  intervals,  sometimes  with  many  hours  between 
them ;  they  also  vary  much  in  intensity,  some  being  very  sharp  and 
painful,  while  others  are  slight  and  transient.  In  these  respects  they 
differ  from  the  true  pains  of  the  first  stage,  which  are  at  first  slight 
and  short,  and  gradually  recur  with  increased  force  and  regularity. 
The  situation  of  the  two  kinds  of  pains  also  varies ;  the  false  pains 
being  chiefly  situated  in  front,  while  the  true  pains  are  felt  most  in 
the  back,  and  gradually  shoot  around  toward  the  abdomen.  Nothing 
short  of  a  vaginal  examination  will  enable  us  to  clear  up  the  diagnosis 
satisfactorily.  If  the  labor  have  actually  commenced,  the  os  will  be 
more  or  less  dilated,  and  its  edges  thinned  ;  while  with  each  pain  the 
cervix  will  become  rigid,  and  the  membranes  tense  and  prominent. 
The  false  pains,  on  the  contrary,  have  no  effect  on  the  cervix,  which 
remains  flaccid  and  undilated ;  or,  if  the  os  be  .sufficiently  open  to 
admit  the  tip  of  the  finger,  the  membranes  will  not  become  prominent 


MANAGEMENT  OF  NATURAL  LABOR. 


295 


during  the  contraction.  Under  such  circumstances  we  may  confidently 
assure  the  patient  that  the  pains  are  false,  and  measures  should  be 
taken  to  remove  the  irritation  which  produces  them.  In  the  large 
majority  of  cases  the  cause  of  the  spurious  pains  will  be  found  to  be 
some  disordered  state  of  the  intestinal  tract ;  and  they  will  be  best 
remedied  by  a  gentle  aperient — such  as  castor  oil,  or  the  compound 
colocynth  pill  with  hyoscyamus — followed  by,  or  combined  with,  a 
sedative,  such  as  twenty  minims  of  laudanum  or  chlorodyne.  Shortly 
after  this  has  been  administered  the  false  pains  will  die  away,  and  not 
recur  until  true  labor  commences. 

Mode  of  Conducting  a  Vaginal  Examination. — For  a  vaginal 
examination  the  patient  is  placed  by  the  nurse  on  her  left  side,  close 

FIG.  109. 


Examination  during  the  first  stage. 

to  the  edge  of  the  bed,  with  the  legs  flexed  on  the  abdomen.  The 
practitioner  being  seated  by  the  edge  of  the  bed,  passes  the  index 
finger  of  the  right  hand,  the  proper  antiseptic  precautions  having 
previously  been  taken,  up  to  the  vulva,  and  gently  insinuates  it  into 
the  orifice  of  the  vagina,  then  pushes  it  backward  in  the  axis  of  the 
vaginal  outlet,  and  finally  turns  it  upward  and  forward  so  as  to  more 
readily  reach  the  cervix  (Fig.  .109).  This  it  may  not  always  be  easy 
to  do,  for  at  the  commencement  of  labor  the  cervix  may  be  so  high  as 
to  be  reached  with  difficulty,  or  it  may  be  directed  backward  so  as  to 
point  toward  the  cavity  of  the  sacrum.  The  exploration  is  often 
much  facilitated  by  depressing  the  uterus  from  without,  by  the  left 
hand  placed  on  the  abdomen.  Our  object  is  not  only  to  ascertain 
the  state  of  the  cervix  as  to  softness  and  dilatation,  but  also  the 
presentation,  the  condition  of  the  vagina,  and  the  capacity  of  the 


296  LABOR. 

pelvis.  The  examination  is  generally  commenced  during  a  pain,  at 
which  time  it  is  less  depressing  to  the  patient ;  but  in  order  to  be 
satisfactory  the  finger  must  remain  in  the  vagina  until  the  pain  is 
over,  the  examination  being  concluded  in  the  interval  between  this 
pain  and  the  next. 

In  head  presentations  the  round  mass  of  the  cranium  is  generally  at 
once  felt  through  the  lower  part  of  the  uterus,  and  then  we  have  the 
satisfaction  of  being  able  to  assure  the  patient  that  all  is  right.  If  the 
os  be  sufficiently  dilated,  we  can  also  feel  through  it  the  occiput  covered 
by  the  membranes.  It  is  impossible  at  this  time  to  make  out  the  exact 
position  of  the  head  by  means  of  the  sutures  and  fontanelles,  which  are 
too  high  up  to  be  within  reach.  Nor  should  any  attempt  be  made  to  do 
so,  for  fear  of  prematurely  rupturing  the  membranes.  The  fact  that 
the  head  is  presenting  is  all  that  we  require  to  know  at  this  stage  of 
the  labor. 

The  condition  of  the  os  itself,  as  to  rigidity  and  dilatation,  will 
materially  assist  us  in  forming  an  opinion  as  to  the  progress  and  prob- 
able duration  of  the  labor ;  but,  although  the  friends  will  certainly 
press  for  an  opinion  on  this  point,  the  cautious  practitioner  will  be  care- 
ful not  to  commit  himself  to  a  positive  statement,  which  may  so  easily 
be  falsified.  It  will  suffice  to  assure  the  friends  that  everything  is 
satisfactory,  but  that  it  is  impossible  to  say  with  any  certainty  how 
rapidly,  or  the  reverse,  the  case  may  progress. 

If  the  pains  be  not  very  frequent  or  strong,  and  the  os  not  dilated 
to  more  than  the  size  of  a  shilling,  a  considerable  delay  may  be 
anticipated,  and  the  presence  of  the  medical  attendant  is  useless.  He 
may,  therefore,  safely  leave  the  patient  for  an  hour  or  more,  provided 
he  be  within  easy  reach.  It  is  needless  to  say  that  this  should  never 
be  done  unless  the  exact  presentation  be  made  out.  If  some  part  other 
than  the  head  be  presenting,  it  will  probably  be  impossible  to  make  it 
out  until  dilatation  has  progressed  further ;  and  the  practitioner  must 
be  incessantly  on  the  watch  until  the  nature  of  the  case  be  made  out, 
so  as  to  be  able  to  seize  the  most  favorable  moment  for  interference, 
should  that  be  necessary. 

Position  of  Patient  during  First  Stage. — The  position  of  the 
patient  in  the  first  stage  is  a  matter  of  some  moment.  It  is  a  decided 
advantage  that  she  should  not  be  then  in  a  recumbent  position  on  her 
side,  as  is  usual  in  the  second  stage ;  for  it  is  of  importance  that  the 
expulsive  force  should  act  in  such  a  way  as  to  favor  the  descent  of  the 
head  into  the  pelvis,  i.  e.,  perpendicularly  to  the  plane  of  its  brim,  and ' 
also  that  the  weight  of  the  child  should  operate  in  the  same  way. 
Therefore,  the  ordinary  custom  of  allowing  the  patient  to  walk  about, 
or  to  recline  in  a  chair,  is  decidedly  advantageous ;  and  it  will  often 
be  observed  that  the  pains  are  more  lingering  and  ineffective  if  she  lie 
in  bed.  If  the  patient  be  a  multipara,  or  if  the  abdomen  be  somewhat 
pendulous,  an  abdominal  bandage,  by  supporting  the  uterus,  will 
greatly  favor  the  progress  of  this  stage.  Keeping  the  patient  out  of 
bed  has  the  further  advantage  of  preventing  her  being  unduly  anxious 
for  the  termination  of  the  labor ;  and  a  little  cheerful  conversation 
will  keep  up  her  spirits,  and  obviate  the  mental  depression  which  is 


MANAGEMENT  OF  NATURAL  LABOR.         297 

so  common.  Good  beef-tea  may  be  freely  administered,  with  a  little 
brandy-and-water  occasionally  if  the  patient  be  weak,  and  will  be 
useful  in  supporting  her  strength. 

Over-freqnent  vaginal  examinations  at  this  period  should  be  avoided, 
for  they  serve  no  useful  purpose,  and  are  apt  to  irritate  the  cervix.  It 
will  be  necessary,  however,  to  ascertain  the  progress  of  the  dilatation 
at  intervals. 

When  once  the  os  is  fully  dilated  the  membranes  may  be  artificially 
ruptured  if  they  have  not  broken  spontaneously,  for  they  no  longer 
serve  any  useful  purpose,  and  only  retard  the  advent  of  the  propulsive 
stage.  This  can  be  easily  done  by  pressing  on  them,  when  they  are 
rendered  tense  during  a  pain,  by  some  pointed  instrument,  such  as  the 
end  of  a  hairpin,  which  is  always  at  hand.  In  some  cases,  indeed,  it 
is  even  expedient  to  rupture  the  membranes  before  the  os  is  fully 
dilated.  Thus  it  not  unfrequently  happens,  when  the  amount  of 
liquor  amnii  is  at  all  excessive,  that  the  os  dilates  to  the  size  of  a 
five-shilling-piece  or  more ;  but,  although  it  is  perfectly  soft  and 
flaccid,  it  opens  up  no  further  until  the  liquor  amnii  is  evacuated, 
when  the  propulsive  pains  rapidly  complete  its  dilatation.  Some 
experience  and  judgment  are  required  in  the  detection  of  such  cases, 
for  if  we  evacuate  the  liquor  amnii  prematurely  the  pressure  of  the 
head  on  the  cervix  may  produce  irritation,  and  seriously  prolong  the 
labor.  This  manoeuvre  is  most  likely  to  be  useful  when  the  pains  are 
strong  and  the  os  perfectly  flaccid,  but  when  the  membranes  do  not 
protrude  through  the  os  so  as  to  effect  further  dilatation. 

It  is  sometimes  not  easy  to  ascertain  whether  the  membranes  are 
ruptured  or  not.  This  is  most  likely  to  be  the  case  when  the  head  is 
low  down,  and  the  amount  of  liquor  amnii  is  so  small  that  the  pouch 
does  not  become  prominent  during  the  pains.  A  little  care,  however, 
will  enable  us,  if  the  membranes  be  ruptured,  to  feel  the  rugosities  of 
the  scalp  covered  with  hair,  and  to  distinguish  it  from  the  smooth 
polished  surface  of  the  membranes. 

After  the  evacuation  of  the  liquor  amnii  there  is  generally  a  lull  in 
the  progress  of  the  labor,  the  pains,  however,  soon  recurring  with 
increased  force  and  frequency,  and  propelling  the  head  through  the 
pelvic  cavity.  The  change  in  the  character  of  the  pains  is  soon  appre- 
ciated by  the  bearing-down  efforts  by  which  they  are  accompanied,  as 
well  as  by  their  increased  length  and  intensity. 

Position  of  the  Patient  during-  the  Second  Stage. — It  is  now 
advisable  that  the  patient  be  placed  in  bed ;  and  in  England  it  is 
usual  for  her  to  lie  on  her  left  side,  with  her  nates  parallel  to  the  edge 
of  the  bed,  and  her  body  lying  across  it.  This  is  the  established 
obstetric  position  in  our  country,  and  it  would  be  useless  to  attempt  to 
insist  on  any  other,  even  if  it  were  advisable.  Although  the  dorsal 
position  is  preferred  on  the  Continent,  it  is  difficult  to  see  wherein  its 
advantages  consist.  It  certainly  leads  to  unnecessary  exposure  of  the 
person,  and  it  is,  on  the  whole,  less  easy  to  reach  the  patient,  so  placed, 
for  the  necessary  manipulations.  Moreover,  the  dorsal  position  in- 
creases the  risk  of  laceration  of  the  perineum,  by  bringing  the  weight 
of  the  child's  head  to  bear  more  directly  upon  it.  Thus  Schroedcr 


298  LABOR. 

found  that  lacerations  occurred  in  37.6  per  cent,  of  cases  delivered  on 
the  back,  as  against  24.4  per  cent,  in  other  positions. 

The  patient  usually  remains  in  bed  during  the  whole  of  this  stage, 
and  it  is  customary  for  the  nurse  to  tie  to  the  foot  of  the  bed  a  jack- 
towel,  which  is  laid  hold  of  and  used  as  a  support  in  making  bearing- 
down  efforts.  If  the  pains  be  few  and  far  between,  and  the  patient 
finds  it  more  comfortable  to  get  up  occasionally,  there  is  no  reason 
why  she  should  not  do  so.  On  the  contrary,  as  we  shall  subsequently 
see,  in  treating  of  lingering  labor,  the  pains  under  such  circumstances 
are  often  increased  in  the  sitting  posture  in  consequence  of  the  weight 
of  the  child  producing  increased  pressure  on  the  nerves  of  the  vagina. 

At  this  time  vaginal  examination,  which  should  be  more  frequently 
repeated  than  in  the  first  stage,  enables  us  to  ascertain  precisely  the 
position  of  the  head,  by  means  of  the  sutures  and  fontanelles,  as  well 
as  to  watch  its  progress. 

It  not  unfrequently  happens  that  the  head  descends  into  the  pelvis, 
even  to  its  floor,  without  the  os  having  entirely  disappeared.  The 
anterior  lip  especially  is  apt  to  get  caught  between  the  head  and  pubes, 
to  become  swollen  by  the  pressure  to  which  it  is  subjected,  and  thus 
to  retard  the  progress  of  the  labor.  There  can  be  no  reasonable 
objection  to  attempting  to  prevent  this  cause  of  delay  by  pressing  on 
the  incarcerated  lip  during  the  interval  of  the  pains,  so  as  to  push  it 
above  the  head,  and  maintain  it  there  during  the  pains  until  the  head 
descends  below  it.  This  manoauvre,  if  done  judiciously,  and  without 
any  undue  roughness  or  force,  is  certainly  not  liable  to  be  attended  by 
any  of  the  evil  consequences  which  many  obstetricians  have  attributed 
to  it ;  it  is  indeed  a  matter  of  common  sense  that  the  injury  to  the 
cervix  is  likely  to  be  less  if  it  be  pushed  gently  out  of  the  way  than 
if  it  be  left  to  be  tightly  jammed  for  hours  between  the  presenting 
part  and  the  bony  pelvis.  This  mode  of  assistance  is  very  different 
from  the  digital  dilatation  of  a  rigid  cervix,  which  was  formerly  much 
practised,  especially  in  Edinburgh,  in  consequence  of  the  recommenda- 
tion of  Hamilton,  and  which  was  properly  objected  to  by  the  great 
majority  of  obstetricians. 

If  the  pains  be  producing  satisfactory  progress,  no  further  inter- 
ference is  required.  The  medical  attendant  should,  however,  see  that 
the  bladder  is  evacuated ;  and  if  it  have  not  been  so  for  some  hours, 
it  may  be  necessary  to  draw  off  the  urine  by  the  catheter.  Whenever 
the  labor  is  lengthy,  he  should  occasionally  practise  auscultation,  so  as 
to  satisfy  himself  that  the  foetal  circulation  is  being  satisfactorily 
carried  on. 

The  regulation  of  the  bearing-down  efforts  at  this  time  is  of  impor- 
tance. It  is  common  for  the  nurse  to  urge  the  patient  to  help  herself 
by  straining,  and  it  is  certain  that  by  voluntary  action  of  this  kind 
she  can  materially  increase  the  action  of  the  accessory  muscles  of  par- 
turition. If  the  pains  be  strong,  and  the  labor  promise  to  be  rapid, 
such  voluntary  exertions  are  not  likely  to  be  prejudicial.  On  the 
other  hand,  if  the  case  be  progressing  slowly,  they  only  unnecessarily 
fatigue  the  patient,  and  should  be  discouraged.  When  the  perineum 
is  distended  we  may  even  find  it  advisable  to  urge  the  patient  to  cease 


MANAGEMENT  OF  NATURAL  LABOR.         299 

all  voluntary  effort,  and  to  cry  out,  for  the  express  purpose  of  lessen- 
ing the  tension  to  which  the  perineum  is  subjected.  This  is  the  stage 
in  which  anaesthesia  is  most  serviceable,  but  its  employment  must  be 
separately  discussed. 

Distention  of  the  Perineum. — As  the  head  descends  more  and 
more  the  perineum  becomes  distended,  and  there  is  considerable  differ- 
ence of  opinion  amongst  accoucheurs  as  to  the  management  of  the  case 
at  this  time.  In  most  obstetric  works  the  practitioner  is  advised  to 
endeavor  to  prevent  laceration  by  the  manoeuvre  that  is  described  as 
supporting  the  perineum.  By  this  is  meant,  laying  the  palm  of  the 
hand  on  the  distended  structures,  and  pressing  firmly  upon  them 
during  the  acme  of  the  pain,  with  the  view  of  mechanically  pre- 
venting their  tearing.  There  can  be  little  doubt  that  this,  or  some 
modification  of  it,  is  the  practice  followed  by  the  large  majority  of 
practitioners.  Of  late  years  the  evil  effects  likely  to  attend  it  have 
been  specially  dwelt  upon  by  Graily  Hewitt,  Leishman,  Goodell,  and 
other  writers,  who  maintain  that  by  pressure  exerted  in  this  fashion 
we  not  only  fail  to  prevent,  but  actually  favor,  laceration,  in  conse- 
quence of  the  pressure  producing  increased  uterine  action,  just  at  the 
time  when  forcible  disteution  of  the  perineum  is  likely  to  be  hurtful. 
Therefore  some  hold  that  the  perineum  ought  to  be  left  entirely  alone, 
and  that  the  head  should  be  allowed  gradually  to  distend  it,  without 
any  assistance  on  the  part  of  the  practitioner. 

Much  error  may  be  traced  to  a  misconception  of  what  is  required. 
The  term  "supporting  the  perineum"  conveys  an  unquestionably 
erroneous  idea,  and  it  is  certain  that  no  one  can  prevent  laceration  by 
mechanical  support.  If  the  term  relaxation  of  the  perineum  were  em- 
ployed, we  should  have  a  far  more  accurate  idea  of  what  should  be 
aimed  at,  and,  if  this  be  borne  in  mind,  I  think  it  cannot  be  ques- 
tioned that  Xature  may  be  most  usefully  assisted  at  this  stage. 

Dr.  Goodell,  of  Philadelphia,  has  specially  studied  this  subject,  and 
has  recommended  a  method  the  object  of  which  is  to  relax  the  peri- 
neum. His  advice  is,  that  one  or  two  fingers  of  the  left  hand  should 
be  inserted  into  the  rectum,  by  which  the  perineum  should  be  hooked 
up  and  pulled  forward  over  the  head,  toward  the  pubes,  the  thumb  of 
the  same  hand  being  placed  on  the  advancing  head,  so  as  to  restrain 
its  progress  if  needful.  I  have  adopted  this  plan  frequently,  and 
believe  that  it  admirably  answers  its  purpose,  especially  when  the  peri- 
neum is  greatly  distended,  and  laceration  is  threatened.  It  must  be 
admitted  that  the  insertion  of  the  fingers  into  the  anal  orifice,  in  the 
manner  recommended,  is  repugnant  both  to  the  practitioner  and 
patient,  and  the  same  result  can  be  obtained  in  a  less  unpleasant  way. 
I  mention  it,  however,  to  show  what  it  is  that  the  practitioner  must 
aim  at.  If,  when  the  head  is  distending  the  perineum  greatly,  the 
thumb  and  forefinger  of  the  right  hand  are  placed  along  its  sides,  it 
can  be  pushed  gently  forward  over  the  head  at  the  height  of  the  pain, 
while  the  tips  of  the  fingers  may,  at  the  same  time,  press  upon  the 
advancing  vertex,  so  as  to  retard  its  progress  if  advisable  (Fig.  110). 
By  this  means  the  sudden  and  forcible  stretching  of  the  perineal  struc- 
tures is  prevented,  and  the  chance  of  laceration  reduced  to  a  minimum, 


300  LABOR. 

while  Nature's  mode  of  relaxing  the  tissues,  by  dilatation  of  the 
anal  orifice,  is  favored.  This  is  very  different  from  the  mechanical 
support  that  is  usually  recommended,  and  the  less  pressure  that  is 
applied  directly  to  the  perineum  the  better.  Nor  is  it  either  needful  or 
advisable  to  sit  by  the  patient  with  the  hand  applied  to  the  perineum 
for  hours,  as  is  so  often  practised.  Time  should  be  given  for  the 
gradual  distention  of  the  tissues  by  the  alternate  advance  and  recession 
of  the  head,  and  we  need  only  intervene  to  assist  relaxation  when  the 
stretching  has  reached  its  height,  and  the  head  is  about  to  be  expelled. 
A  napkin  may  be  interposed  between  the  hand  and  the  skin,  for  the 
purpose  of  cleanliness.  Should  the  perineum  be  excessively  tough  and 
resistant,  assiduous  fomentation  with  a  hot  sponge  may  be  resorted  to, 
and  will  be  of  some  service  in  promoting  relaxation. 

FIG.  110. 


Mode  of  effecting  relaxation  of  the  perineum. 

Incision  of  the  Perineum. — When  the  tension  is  so  great  that 
laceration  seems  inevitable,  it  is  generally  recommended  that  a  slight 
incision  should  be  made  on  each  side  of  the  central  raphe,  with  the 
view  of  preventing  spontaneous  laceration.  This  may  no  doubt  be 
done  with  perfect  safety,  but  I  question  if  it  is  likely  to  be  of  use. 
The  idea  is  that  an  incised  wound  is  likely  to  heal  more  readily  than 
a  lacerated  one.  When,  however,  a  distended  perineum  ruptures,  its 
structures  are  so  thinned  that  the  tear  is  always  linear;  and,  as  a 
matter  of  fact,  the  edges  of  the  tear  are  always  as  clean,  and  as  closely 
in  apposition,  as  if  the  cut  had  been  made  with  a  knife.  Moreover, 
the  laceration  invariably  heals  perfectly,  if  only  the  edges  be  brought 
into  contact  at  once  with  one  or  two  sutures.  I  believe,  therefore,  that 
Goodell  is  right  in  stating  that  incision  of  the  perineum  is  rarely,  if 
ever,  necessary,  unless  it  is  hardened  by  previous  cicatrization.  In 
almost  all  first  labors  the  fourchette  is  torn,  but  requires  no  treatment 


MANAGEMENT  OF  NATURAL  LABOR.         301 

of  any  kind.  In  some  cases,  do  what  we  will,  more  or  less  laceration 
occurs,  and  the  perineum  should  always  be  examined  after  the  expul- 
sion of  the  child,  to  see  if  any  tear  has  taken  place. 

If  it  has  given  way  to  any  extent,  I  believe  that  it  is  good  practice 
to  insert  one  or  two  interrupted  sutures  of  silver  wire  or  chromic  gut 
at  once.  Immediately  after  delivery  the  sensibility  of  the  tissues  is 
deadened  by  the  distention  to  which  they  have  been  subjected,  and  the 
sutures  can  be  inserted  with  little  or  no  pain.  It  is  quite  true  that 
lacerations  of  an  inch  or  less  will  generally  heal  perfectly  well  of  them- 
selves; but  this  is  not  invariably  the  case,  while  healing  almost  cer- 
tainly follows  if  the  edges  be  brought  together  at  once.  In  the  severer 
forms  of  laceration,  extending  back  to,  or  even  through,  the  sphincter, 
the  precaution  is  all  the  more  necessary,  and  a  subsequent  operation  of 
gravity  may  in  this  way  be  avoided.  The  sutures  can  be  removed 
without  difficulty  ill  a  week  or  so,  when  complete  adhesion  has  taken 
place. 

Expulsion  of  the  Child. — The  head,  when  expelled,  should  be 
received  in  the  palm  of  the  right  hand,  while  the  left  hand  is  placed 
upon  the  abdomen  to  follow  down  the  uterus  as  it  contracts  and  expels 
the  body.  There  is  generally  some  little  delay  after  the  expulsion  of 
the  head,  an4  we  should  now  see  if  the  cord  surround  the  neck,  and, 
if  it  does  so,  it  should  be  drawn  over  the  head,  and,  if  this  is  not  pos- 
sible, it  may  be  tied  and  divided  between  the  ligatures.  The  expulsion 
of  the  body  should  be  left  entirely  to  the  uterine  contractions.  If 
there  be  undue  delay  we  may  endeavor  to  excite  uterine  action  by  fric- 
tion on  the  fundus,  and  it  will  rarely  happen  that  sufficient  contraction 
does  not  now  come  on.  If  we  display  undue  haste  in  withdrawing 
the  body,  we  run  the  risk  of  emptying  the  uterus  while  its  tissues  are 
relaxed,  and  so  favor  hemorrhage.  If,  however,  there  seems  serious 
danger  of  the  child  being  asphyxiated,  its  expulsion  may  be  favored 
by  gently  passing  the  forefinger  of  each  hand  within  the  axilla?,  and 
using  traction ;  but  it  is  only  very  exceptionally  that  such  interference 
is  required. 

Promotion  of  Uterine  Contraction  after  the  Birth  of  the 
Child. — As  the  uterus  contracts,  it  should  be  carefully  followed  down 
through  the  abdominal  parietes  by  the  left  hand,  which  should  grasp 
it  as  the  body  is  expelled,  with  the  view  of  seeing  that  it  is  efficiently 
contracted.  This  is  a  point  of  vital  importance  in  preventing  hemor- 
rhage, which  will  presently  be  more  especially  considered. 

As  soon  as  the  child  cries  we  may  proceed  to  tie  and  separate  the 
cord.  For  this  purpose  the  nurse  usually  provides  ligatures  composed 
of  several  strands  of  whitey -brown  thread;  but  tape,  or  any  other 
suitable  material,  may  be  employed.  It  is  important,  especially  if  the 
cord  be  very  thick  and  gelatinous,  to  see  that  it  is  thoroughly  com- 
pressed, so  that  the  vessels  are  obliterated,  otherwise  secondary  hemor- 
rhage might  occur.  The  cord  is  tied  about  an  inch  and  a  half  from 
the  child,  and  it  is  usual,  though,  of  course,  not  essential,  to  place  a 
second  ligature  about  two  inches  nearer  the  placental  extremity  of  the 
cord.  The  latter  is,  perhaps,  of  some  use  by  retaining  the  blood,  and 
thus  increasing  the  size  of  the  placenta,  and  favoring  its  more  ready 


302  LABOR. 

expulsion  by  uterine  contraction.  The  cord  is  then  divided  with 
scissors  between  the  ligatures,  the  child  wrapped  up  in  flannel,  and 
given  to  the  nurse,  or  to  a  bystander,  to  hold,  while  the  attention  of 
the  practitioner  is  concentrated  on  the  mother,  with  a  view  to  the 
proper  management  of  the  third  stage  of  labor.  The  researches  of 
Budin,1  Ribemont,2  and  others  show  that  there  is  a  distinct  advantage 
in  not  tying  the  cord  until  the  child  has  cried  lustily,  as  the  act  of 
respiration  tends  to  withdraw  the  placental  blood,  and  thus  increases 
the  entire  amount  of  blood  in  the  fetus.  It  is  said  that  after  late 
ligature  of  the  cord  the  child  is  more  vigorous  and  active  than  when 
it  is  tied  too  early. 

The  cord  may,  if  preferred,  be  treated  with  perfect  safety  by  lacera- 
tion. This  method  was  first  brought  under  my  notice  by  the  late  Dr. 
Stephen,  who  employed  it  for  many  years,  and  in  several  hundred 
cases.  The  cord  is  twisted  round  the  index  fingers  of  both  hands,  and 
torn  through,  the  lacerated  vessels  retracting  without  any  hemorrhage. 
It  is  a  close  imitation  of  the  method  instinctively  adopted  by  the 
lower  animals,  who  gnaw  the  cord  asunder,  and  has  the  advantage  of 
dispensing  with  ligatures  altogether.  I  have  used  it  myself  in  a  large 
number  of  cases,  but  prefer,  on  the  whole,  the  plan  usually  adopted. 

Importance  of  Proper  Management  of  Third  Stage. — There  is 
unquestionably  no  period  of  labor  where  skilled  management  is  more 
important,  and  none  in  which  mistakes  are  more  frequently  made. 
By  proper  care  at  this  time  the  risk  of  post-partum  hemorrhage  is 
reduced  to  a  minimum,  the  efficient  contraction  of  the  uterus  is  secured, 
the  amount  and  intensity  of  after-pains,  are  lessened,  and  the  safety  and 
comfort  of  the  patient  greatly  promoted.  Moreover,  the  general  prac- 
tice, as  to  the  management  of  this  stage,  is  opposed  to  the  natural 
mechanism  of  placental  expulsion,  and  is  far  from  being  well  adapted 
to  secure  the  important  objects  which  we  ought  to  have  in  view.  Let 
us  see  what  is  the  practice  usually  recommended  and  followed,  and 
then  we  shall  be  in  a  position  to  understand  in  what  respects  it  is 
erroneous.  For  this  purpose  I  cannot  do  better  than  copy  the  direc- 
tions contained  in  one  of  our  most  deservedly  popular  obstetric  text- 
books, which  undoubtedly  expresses  the  usual  practice  in  the  manage- 
ment of  this  stage :  "  When  the  binder  is  applied,  the  patient  may  be 
allowed  to  rest  a  while,  if  there  is  no  flooding ;  after  which,  when  the 
uterus  contracts,  gentle  traction  may  be  made  by  the  funis,  to  ascertain 
if  the  placenta  be  detached.  If  so,  and  especially  if  it  be  in  the 
vagina,  it  may  be  removed  by  continuing  the  traction  steadily  in  the 
axis  of  the  upper  outlet  at  first,  at  the  same  time  making  pressure  on 
the  uterus."3 

[In  this  country,  for  many  years,  the  uniform  teaching  has  been 
that  the  binder  should  not  be  applied  until  the  uterus  has  expelled  the 
placenta  and  become  firmly  contracted.  Although  the  plan  of  expres- 
sion was  not  carried  out  as  completely  as  is  now  taught  under  the  Crede 
method,  that  of  stimulating  the  contractions  of  the  uterus  by  rnanipu- 

1  Budin  :  Progres  Medical,  1876.  torn.  iv.  pp.  2,  36. 

2  Archiv.  de  Tocologie,  1879,  p.  577. 

8  Churchill's  Theory  and  Practice  of  Midwifery,  p.  162. 


MANAGEMENT  OF  NATURAL  LABOR.         803 

lation  and  pressure  was  certainly  in  use  forty  years  ago.  When  the 
size. and  solidity  of  the  uterus,  as  ascertained  by  the  compressing  hand, 
indicate  that  the  placenta  has  been  expelled  into  the  vagina,  it  is  a 
question  whether  we  shall  cause  ii  to  be  forced  through  the  vulva  by 
pressing  down  the  uterus  upon  it,  or  make  traction  upon  it  by  the 
finger  hooking  down  its  edge.  Occasionally  we  find  a  patient  who 
is  very  sensitive  to  pressure  made  upon  her  uterus  after  it  has  become 
firmly  contracted ;  and  in  such  a  case  it  may  be  well  to  depend  partly 
upon  traction  for  completing  the  delivery  of  the  secundines.  That  it 
is  possible  for  the  uterus  to  expel  the  placenta  suddenly  from  the  vagina 
where  no  pressure  has  been  made  is  evident  from  the  fact  that  a  physi- 
cian of  this  city,  who  was  making  traction  upon  the  cord  under  the  old 
method  some  years  ago,  was  surprised  to  find  the  placenta  shoot  out 
from  the  vulva  and  dangle  by  the  funis  as  he  held  it  in  his  hand.  In 
such  a  case  the  uterus  must  have  been  aided  during  a  contraction  by 
voluntary  abdominal  pressure,  causing  the  os  to  descend  nearly  to  the 
vulva.  It  is  very  evident  that  the  uterus  is  subject  to  muscular  fatigue 
and  to  the  exhaustion  of  its  contractile  power  when  long  in  action ; 
hence  there  is  a  greater  risk  of  uterine  atony  and  hemorrhage  after  a 
long  labor  than  a  short  one,  and  we  may  expect  a  more  complete  expul- 
sion of  the  placenta  in  the  latter.  It  is  also  clear,  from  cases  in  my 
own  experience,  that  the  muscular  power  of  the  uterus  is  by  no  means 
in  proportion  to  the  general  strength  of  the  woman.  The  power  to 
assist  by  bearing  down  no  doubt  is,  but  the  independent  power  of  the 
organ  itself  does  not  appear  to  be.  Certainly  some  of  the  most  perfect 
in  parturient  power  that  have  come  under  my  care  were  small  women 
with  little  general  muscular  force.  One  little  woman  of  eighty-six 
pounds  weight  appeared  almost  to  have  escaped  the  curse  pronounced 
upon  Eve ;  and  another,  still  smaller,  expelled  a  placenta  from  her 
vagina  almost  without  any  loss  of  blood. — ED.] 

This  may  fairly  be  taken  as  a  sufficiently  accurate  description  of  the 
practice  usually  followed.1  The  objections  I  have  to  make  are:  1. 
That  it  inculcates  the  common  error  of  relying  on  the  binder  as  a 
means  of  promoting  uterine  contraction,  advising  its  application  before 
the  expulsion  of  the  placenta ;  while  I  hold  that  the  binder  should 
never  be  applied  until  after  the  placenta  is  expelled,  and  not  even  then, 
unless  the  uterus  is  perfectly  and  permanently  contracted.  2.  That  it 
teaches  that  traction  on  the  cord  should  be  used  as  a  means  of  with- 
drawing the  placenta;  whereas  the  uterus  itself  should  be  made  to 
expel  the  afterbirth,  and  in  nineteen  cases  out  of  twenty,  the  finger 
need  never  be  introduced  into  the  vagina  after  the  birth  of  the  child, 
nor  the  cord  touched.  This  may  seem  an  exaggerated  statement  to 
those  who  have  accustomed  themselves  to  the  usual  method  of  dealing 
with  the  placenta ;  but  I  feel  confident  that  all  who  have  learnt  the 
method  of  expression  would  testify  to  its  accuracy. 

Expression  of  the  Placenta :  Its  Object. — The  cardinal  point"  to; 
bear  in  mind  is,  that  the  placenta  should  be  expelled  from  the  uterus! 

1  This  practice  is  further  illustrated  by  the  annexed  diagram,  contained  in  most  obstetric  works, 
which  represents  the  accoucheur  as  withdrawing  the  placenta  by  traction,  and  which  I  insert  as 
an  illustration  of  what  ought  not  to  be  done  (Fig.  111). 


304 


LABOR. 


by  a  vis  a  tergo,  not  drawn  out  by  a  vis  a  f route.  That  uterine  pressure 
after  the  birth  of  the  child  has  been  recommended  by  many  English 
writers  is  certain,  and  the  Dublin  school  especially  have  dwelt  on  its 
importance  as  a  preventive  of  post-partum  hemorrhage  ;  but  the  dis- 
tinct enunciation  of  the  doctrine  that  the  placenta  should  be  pressed, 
and  not  drawn  out  of  the  uterus,  we  owe  to  Crede  and  other  German 
writers ;  and  it  is  only  of  late  years  that  this  practice  has  become  at 
all  common.  Those  who  have  not  seen  placental  expression  practised 
find  it  difficult  to  understand  that,  in  the  large  majority  of  cases,  the 
uterus  may  be  made  to  expel  the  placenta  out  of  the  vagina ;  but  such 


FIG.  111. 


Usual  method  of  removing  the  placenta  by  traction  on  the  cord. 

is  unquestionably  the  fact.  A  little  practice  is  no  doubt  necessary  to 
effect  this  satisfactorily ;  but  when  once  the  knack  has  been  learned, 
there  is  little  difficulty  likely  to  be  experienced. 

Before  describing  the  method  of  placental  expression,  a  wrord  of 
caution  may  be  said  against  undue  haste  in  attempting  expression  of 
the  placenta,  a  mistake  that  is  often  made,  and  which,  I  believe,  tends 
to  increase  the  risk  of  post-partum  hemorrhage.  So  long  as  we  satisfy 
ourselves  that  the  uterus  is  fairly  contracted  so  as  to  avoid  the  possi- 
bility of  its  distention  with  blood,  a  certain  delay  after  the  birth  of  the 
child  is  useful,  from  its  giving  time  for  coagula  to  form  within  the 
uterine  sinuses,  by  which  their  open  mouths  are  closed  up.  The  im- 
portance of  this  point  has  been  specially  dwelt  upon  by  McClintock, 
who  lays  down  the  rule  that  fifteen  or  twenty  minutes  should  be  allowed 
to  elapse  after  the  birth  of  the  child,  before  any  attempt  to  remove  the 
afterbirth  is  made.  This  is  a  good  and  safe  practical  rule,  as  it  gives 
ample  time  for  the  complete  detachment  of  the  placenta  and  the  coagu- 
lation of  the  blood  in  the  uterine  sinuses. 


MANAGEMENT    O-F    NATURAL    LABOR. 


305 


During  this  interval  the  practitioner  or  nurse  should  sit  by  the  bed- 
side, with  the  hand  on  the  uterus  to  secure  contraction  and  prevent  dis- 
tention ;  but  not  kneading  or  forcibly  compressing  it.  When  we  judge 
that  a  sufficient  time  has  elapsed,  we  may  proceed  to  effect  expulsion. 
For  this  purpose  the  fundus  should  be  grasped  in  the  hollow  of  the 
left  hand,  the  ulnar  edge  of  the  hand  being  well  pressed  down  behind  the 
fundus,  and,  when  the  uterus  is  felt  to  harden,  strong  and  firm  pressure 
should  be  made  downward  and  backward  in  the  axis  of  the  pelvic  brim. 
If  this  manoeuvre  be  properly  carried  out,  and  sufficiently  firm  pressure 
made,  in  almost  every  case  the  uterus  may  be  made  to  expel  the  placenta 
into  the  bed,  along  with  any  coagula  that  may  be  in  its  cavity  (Fig. 


FIG.  112. 


Illustrating  expression  of  the  placenta. 

112).  The  uterine  surface  of  the  placenta  is  generally  expelled  first,  as 
is  represented  in  the  diagram,  the  cord  being  within  the  membranes ; 
whereas  the  foetal  surface,  and  root  of  the  cord,  are  the  parts  which 
appear  first  when  the  placenta  is  removed  by  traction  (Fig.  111).  If 
we  do  not  succeed  at  the  first  effort,  which  is  rarely  the  case  if  extru- 
sion be  not  attempted  too  soon  after  the  birth  of  the  child,  we  may  wait 
until  another  contraction  takes  place,  and  then  reapply  the  pressure. 
I  repeat  that,  after  a  little  practice,  the  placenta  may  be  entirely  ex- 
pelled in  this  way,  in  nineteen  cases  out  of  twenty,  without  even  touch- 
ing the  cord,  and  the  bugbear  of  retained  placenta  will  cease  to  be  a 
source  of  dread. 

Should  we  fail  in  causing  the  uterus  to  expel  the  placenta,  a  vaginal 
examination  may  be  made,  and,  if  the  placenta  be  found  lying  entirely 
in  the  vagina,  it  may  be  carefully  withdrawn.  If,  however,  the  cord 
can  be  traced  up  through  the  os,  showing  that  the  placenta  is  still 
within  the  uterine  cavity,  we  must  again  resort  to  pressure  to  effect  its 
expulsion,  and  not  attempt  to  withdraw  it  by  traction.  Such  cases 
may  fairly  be  classed  as  retained  placenta,  but  they  should  be  very 
rarely  met  with,  and  are  discussed  elsewhere.  When  they  do  occur 

20 


306  LABOR. 

often  in  the  hands  of  the  same  practitioner,  it  is  fair  to  conclude  that 
he  has  not  properly  acquired  the  art  of  managing  this  stage  of  labor. 
Generally  speaking,  the  placenta  should  be  expelled  within  twenty 
minutes  after  the  birth  of  the  child ;  but  no  'doubt,  in  the  large  ma- 
jority of  cases,  expulsion  might  be  effected  sooner  were  it  advisable  to 
attempt  it. 

Management  of  the  Membranes. — When  the  mass  of  the  placenta 
is  expelled,  the  membranes  generally  still  remain  in  the  vagina,  and 
they  should  be  twisted  into  a  rope,  and  very  gently  withdrawn,  so  as 
not  to  leave  any  portion  behind.  This  is  a  precaution  the  importance 
of  which  I  would  strongly  urge,  for  I  believe  that  the  chance  of  part 
of  the  membranes  being  torn  off  and  left  in  utero  is  the  one  objection 
to  the  method  recommended.  With  due  care,  however,  this  accident 
may  be  avoided,  and  the  risk  will  be  lessened  if  the  placenta  is  received 
into  the  palm  of  the  right  hand,  on  expression,  so  as  to  avoid  any 
strain  on  the  membranes. 

The  duties  of  the  medical  attendant  are  not  even  now  over.  For 
at  least  ten  minutes  after  the  extrusion  of  the  placenta,  he  should  keep 
his  hand  on  the  firmly  contracted  uterus,  gently  kneading  it,  without 
any  force,  for  the  purpose  of  promoting  firm  and  equable  contraction, 
and  causing  it  to  throw  off  the  coagula  that  may  form  in  its  cavity. 

The  subsequent  comfort  and  safety  of  the  patient  may  be  promoted 
by  administering  at  this  time  a  full  dose  of  ergot  of  rye,  such  as  a 
drachm,  or  more,  of  the  liquid  extract.  The  property  possessed  by 
this  drug  of  producing  tonic  and  persistent  contraction  of  the  uterine 
fibres,  which  renders  it  of  doubtful  utility  as  an  oxytocic  during  labor, 
is  of  special  value  after  delivery,  when  such  contraction  is  precisely 
what  we  desire.  I  have  long  been  in  the  habit  of  administering  the 
drug  at  this  period,  and  believe  it  to  be  of  great  value,  not  only  as  a 
prophylactic  against  hemorrhage,  but  as  a  means  of  lessening  after- 
pains. 

Examination  of  the  Placenta. — The  accoucheur  should  always 
satisfy  himself  as  to  the  integrity  of  the  placenta,  and  not  be  satisfied 
with  the  report  of  the  nurse.  It  should  be  carefully  examined  in 
every  case,  to  make  sure  that  no  portion  of  it,  nor  of  the  membrane,  is 
left  behind.  It  is  well  to  re-invert  the  membranes,  and  examine  the 
uterine  surface  of  the  placenta  in  the  first  instance,  and  then  to  satisfy 
oneself  that  the  membranes,  both  chorion  and  amnion,  are  entire.  If 
any  portion  is  absent,  it  must  be  carefully  searched  for  in  the  clots,  or 
in  the  vagina  or  uterine  cavity.  Should  it  be  necessary  to  introduce 
the  finger  or  hand  for  this  purpose,  even  when  carefully  asepticized, 
the  uterus  should  subsequently  be  washed  out  with  a  douche  of  hot 
water  at  110°  F.,  to  which  a  few  drops  of  creolin  have  been  added,  or 
with  a  solution  of  perchloride  of  mercury  (1  :  2000),  at  the  same 
temperature. 

Application  of  the  Binder. — When  we  are  satisfied  that  the  uterus 
is  permanently  contracted,  we  may  apply  the  binder,  but  this  should 
rarely  be  done  until  at  least  half  an  hour  after  the  birth  of  the  child. 
The  soiled  clothes  should  be  gently  withdrawn  from  under  the  patient, 
moving  her  as  little  as  possible,  and  the  binder  should  be,  at  the  same 


MANAGEMENT  OF  NATURAL  LABOR.         307 

time,  slipped  under  the  body,  taking  care  that  it  is  passed  well  below 
the  hips  so  as  to  secure  a  firm  hold.  No  kind  of  bandage  is  better 
than  a  piece  of  stout  jean,  of  sufficient  breadth  to  extend  from  the 
trochanters  to  the  ensiform  cartilage ;  a  jack-towel  or  bolster  slip 
answers  the  purpose  very  well.  These  are  preferable,  at  any  rate  at 
first,  to  the  shaped  binders  that  are  often  used.  One  or  two  folded 
napkins  are  generally  placed  over  the  uterus,  so  as  to  form  a  pad  to 
keep  up  the  pressure.  Once  in  position,  the  binder  is  pulled  tight, 
and  fastened  by  pins.  The  utility  of  careful  bandaging  after  delivery 
can  scarcely  be  doubted,  although  some  years  ago  it  became  the  fashion 
to  dispense  with  it.  It  gives  a  comfortable  support  to  the  lax  abdom- 
inal walls,  keeps  up  a  certain  amount  of  pressure  on  the  uterus,  and 
tends  to  restore  the  figure  of  the  patient.  After  the  bandage  is 
applied,  a  warm  antiseptic  pad  or  napkin  should  be  placed  on  the 
vulva,  as  a  means  of  estimating  the  quantity  of  the  discharge,  and  the 
patient  may  be  allowed  to  rest. 

Examination  of  the  Perineum. — In  every  case,  especially  in  pri- 
miparaB,  the  perineum  should  be  visually  examined.  This  can  easily  be 
done  after  the  placenta  is  expelled,  without  distressing  the  patient.  If 
this  precaution  were  habitually  adopted  many  lacerations  would  be 
detected,  which  would  otherwise  escape  observation. 

After-Treatment. — Unless  the  labor  has  been  very  long  and  fati- 
guing, an  opiate,  often  exhibited  as  a  matter  of  routine,  is  unadvisable  ; 
although  it  may  be  well  to  leave  one  with  the  nurse,  to  be  given  if  the 
patient  cannot  sleep,  or  if  the  after-pains  be  very  troublesome.  The 
practitioner  may  now  leave  the  room,  but  not  the  house,  and  at  least 
an  hour  should  elapse  after  delivery  before  he  takes  his  departure. 
Before  doing  so  he  should  visit  the  patient,  inspect  the  napkin  to  see 
that  there  is  not  too  much  discharge,  and  satisfy  himself  that  the 
uterus  is  contracted,  and  not  distended  with  coagula.  He  should  also 
count  the  pulse,  which,  if  the  patient  be  progressing  satisfactorily,  will 
found  at  its  normal  average.  If,  however,  it  be  beating  over  100  per 
minute,  he  should  on  no  account  leave,  for  such  a  rapidity  of  the  cir- 
culation renders  it  extremely  probable  that  hemorrhage  is  impending. 
This  is  a  good  practical  rule  laid  down  by  McClintock  in  his  excellent 
paper  "  On  the  Pulse  in  Childbed,"  attention  to  which  may  often  save 
the  patient  from  disastrous  consequences. 

Before  leaving,  the  practitioner  should  see  that  the  room  is  darkened, 
all  bystanders  excluded,  and  the  patient  left  as  quiet  as  possible  to 
recover  from  the  shock  of  labor. 


308  LABOR. 


CHAPTER  IY. 

ANAESTHESIA  IN  LABOR. 

A  FEW  words  may  be  said  as  to  the  use  of  anaesthetics  during  labor, 
a  practice  which  has  become  so  universal  that  no  argument  is  required 
to  establish  its  being  a  perfectly  legitimate  means  of  assuaging  the  suf- 
ferings of  childbirth.  Indeed  the  tendency  in  the  present  day  is  in 
the  opposite  direction ;  and  a  common  error  is  the  administration  of 
chloroform  to  an  extent  which  materially  interferes  with  the  uterine 
contractions  and  predisposes  to  subsequent  post-partum  hemorrhage. 

Agents  Employed. — Practically  speaking,  the  only  agent  hitherto 
employed  in  this  country  is  chloroform,  although  the  bichloride  of 
methylene,  and  ether,  have  been  occasionally  tried.  Of  late  years, 
chloral  has  been  extensively  used  by  some ;  and  as  I  believe  it  to  be 
an  agent  of  very  great  value,  I  shall  first  indicate  the  circumstances 
under  which  it  may  be  employed. 

Chloral. — The  peculiar  value  of  chloral  in  labor  is,  that  it  may  be 
safely  administered  at  a  time  when  chloroform  cannot  be  generally 
employed.  The  latter,  while  it  annuls  suffering,  very  frequently 
tends,  in  a  marked  degree,  to  diminish  uterine  action.  This  is  a 
familiar  observation  to  all  who  have  employed  it  much  during  labor, 
as  the  diminution  of  the  force  and  intensity  of  the  pains,  and  the  con- 
sequent retardation  of  the  labor,  often  oblige  us  to  supend  its  inhala- 
tion, at  least  temporarily.  Indeed,  this  very  property  of  annulling 
uterine  action  is  one  of  its  most  valuable  qualities  in  obstetrics,  as  in 
certain  cases  of  turning.  For  such  purposes  it  is  necessary  to  give  it 
to  the  surgical  extent,  which  we  endeavor  to  avoid  when  it  is  used 
simply  to  lessen  the  suffering  of  ordinary  labor.  Still  it  is  not  ahvays 
easy  to  limit  its  action  in  this  way,  and  thus  it  very  frequently  does 
more  than  we  wish.  Such  diminution  in  the  intensity  of  uterine  con- 
traction is  comparatively  of  less  consequence  in  the  propulsive  stage, 
and  it  is  generally  more  than  counterbalanced  by  the  relief  it  affords. 
In  the  first  stage  it  is  otherwise,  and,  practically  speaking,  chloroform 
is  generally  not  admissible  until  the  head  is  in  the  pelvic  cavity. 

Chloral,  on  the  other  hand,  has  no  such  relaxing  effects  on  uterine 
contraction.  It  cannot,  it  is  true,  compete  with  chloroform  in  its 
power  of  relieving  pain,  but  it  produces  a  drowsy  state  in  which  the 
pain  is  not  felt  nearly  so  acutely  as  before.  It  is,  therefore,  in  the 
first  stage  of  labor,  while  the  pains  are  cutting  and  grinding,  and 
during  the  dilatation  of  the  cervix,  that  it  finds  its  most  useful  appli- 
cation. It  is  especially  valuable  in  those  cases,  so  frequently  met 
with  in  the  upper  classes,  in  which  the  pains  produce  intolerably 
acute  suffering,  but  with  little  effect  on  the  progress  of  the  labor.  In 


ANESTHESIA    IN    LABOR.  309 

them  the  os  is  often  thin  and  rigid,  and  the  pains  very  frequent  and 
acute,  but  little  or  no  dilatation  is  effected.  When  the  patient  is  brought 
under  the  influence  of  chloral,  however,  the  pains  become  less  frequent 
but  stronger,  nervous  excitement  is  calmed,  and  the  dilatation  of  the 
cervix  often  proceeds  rapidly  and  satisfactorily.  Indeed,  I  know  of 
nothing  which  answers  so  well  in  cases  of  rigid,  undilatable  cervix, 
and  I  believe  it  to  be  far  more  effective,  under  such  circumstances, 
than  any  of  the  remedies  usually  employed. 

The  object  is  to  produce  a  somnolent  condition,  which  shall  be  pro- 
tracted as  long  as  possible.  For  this  purpose  fifteen  grains  of  chloral 
may  be  administered  every  twenty  minutes,  until  three  doses  are 
given.  This  generally  suffices  to  produce  the  desired  effect.  The 
patient  becomes  very  drowsy,  dozes  between  the  pains,  and  wakes  up 
as  each  contraction  commences.  It  may  be  necessary  to  give  a  fourth 
dose  at  a  longer  interval,  say  an  hour  after  the  third  dose,  to  keep  up 
and  prolong  the  soporific  action  ;  but  this  is  seldom  necessary,  and  I 
have  rarely  given  more  than  forty  to  fifty  grains  of  chloral  during  the 
entire  progress  of  labor.  Another  advantage  of  this  treatment  is  that, 
while  it  does  not  interfere  with  the  use  of  chloroform  in  the  second 
stage,  it  renders  it  necessary  to  give  less  than  otherwise  would  be 
called  for  and  thus  its  action  can  be  more  easily  kept  within  bounds. 
On  the  whole,  therefore,  I  am  inclined  to  consider  chloral  a  very 
valuable  aid  in  the  management  of  labor,  and  believe  that  it  is 
destined  to  be  much  more  extensively  used  than  is  at  present  the  case. 
So  far  as  my  experience  has  yet  gone,  I  have  not  met  with  any  symptoms 
which  have  led  me  to  think  that  it  has  produced  bad  effects ;  and  I 
have  known  many  patients  sleep  quietly  through  labor,  without  ex- 
pressing any  excessive  suffering,  or  asking  for  chloroform,  who,  under 
ordinary  circumstances,  would  have  been  most  urgently  calling  for 
relief.  It  occasionally  happens  that  the  patient  cannot  retain  the 
chloral,  from  its  tendency  to  produce  sickness  ;  it  may  then  be  readily 
given  per  rectum  in  the  form  of  enema. 

Generally  speaking,  we  do  not  think  of  giving  chloroform  until  the 
os  is  fully  dilated,  the  head  descending,  and  the  pains  becoming  pro- 
pulsive. It  has  often,  indeed,  been  administered  earlier,  for  the 
purpose  of  aiding  the  dilatation  of  a  rigid  cervix,  and  there  is  no 
doubt  that  it  often  succeeds  well  when  employed  in  this  way ;  but  I 
have  already  stated  my  belief  that  chloral  answers  this  purpose  better. 

There  is  one  cardinal  rule  to  be  remembered  in  giving  chloroform 
during  the  propulsive  stage,  and  that  is,  that  it  should  be  administered 
intermittently,  and  never  continuously.  When  the  pain  comes  on  a 
few  drops  may  be  scattered  over  a  Skinner's  inhaler,  which  affords  one 
of  the  best  means  of  administering  it  in  labor,  or  placed  within  the 
folds  of  a  handkerchief  twisted  into  the  form  of  a  cone.  During  the 
acme  of  the  pain  the  patient  inhales  it  freely,  and  at  once  experiences  a 
sense  of  great  relief;  and,  as  soon  as  the  pain  dies  away,  the  inhaler 
should  be  removed.  In  the  interval  between  the  pains  the  effect  of 
the  drug  passes  off,  so  that  the  higher  degree  of  anesthesia  should 
never  be  produced.  Indeed,  when  properly  given,  consciousness 
should  not  be  entirely  abolished,  and  the  patient,  between  the  pains, 


310  LABOR. 

should  be  able  to  speak,  and  to  understand  what  is  said  to  her.  This 
intermittent  administration  constitutes  the  peculiar  safety  of  chloro- 
form administered  in  labor,  and  it  is  a  fortunate  circumstance  that 
there  are  very  few  cases  on  record  of  death  during  the  inhalation  of 
chloroform  for  obstetric  purposes.  This  is  obviously  due  to  the  effect 
of  each  inhalation  passing  off  before  a  fresh  dose  is  administered. 

The  effect  on  the  pains  should  be  carefully  watched.  If  they 
become  very  materially  lessened  in  force  and  frequency,  it  may  be 
necessary  to  stop  the  inhalation  for  a  short  time,  commencing  again 
when  the  pains  get  stronger  ;  this  effect  may  be  often  completely  and 
easily  prevented  by  mixing  the  chloroform  with  about  one-third  of 
absolute  alcohol,  which,  originally  recommended,  I  believe,  by  Dr. 
Sansom,  increases  the  stimulating  effects  of  chloroform,  and  thus 
diminishes  its  tendency  to  produce  undue  relaxation.  The  amount 
administered  must  vary,  of  course,  with  the  peculiarities  of  each  indi- 
vidual case  and  the  effect  produced,  but  it  need  never  be  large.  As 
the  head  distends  the  perineum,  and  the  pains  get  very  strong  and 
forcing,  it  may  be  given  more  freely  and  to  the  extent  of  inducing 
even  complete  insensibility  just  before  the  child  is  born. 

Ether. — In  cases  in  which  chloroform  has  lessened  the  force  of  the 
pains,  ether  may  be  given  instead  with  great  advantage.  It  certainly 
often  acts  well  when  chloroform  is  inadmissible  on  account  of  its  effects 
on  the  pains,  and,  so  far  as  my  experience  goes,  it  has  not  the  property 
of  relaxing  the  uterus,  but,  on  the  contrary,  has  sometimes  seemed  to 
me  distinctly  to  intensify  the  pains.  Of  late  I  have  used  a  mixture  of 
one  part  of  absolute  alcohol,  two  of  chloroform,  and  three  of  ether. 
This  is  less  disagreeable  than  ether,  and  has  not  the  over-relaxing 
effects  of  chloroform,  and,  on  the  whole,  I  believe  it  to  be  the  best 
anaesthetic  for  midwifery  practice. 

Bearing  in  mind  the  tendency  of  chloroform  to  produce  uterine 
relaxation,  more  than  ordinary  precautions  should  always  be  taken 
against  post-partum  hemorrhage  in  all  cases  in  which  it  has  been  freely 
administered. 

In  cases  of  operative  midwifery,  it  is  often  given  to  the  extent  of 
producing  complete  anaesthesia.  In  all  such  cases  it  should  be  admin- 
istered, when  possible,  by  another  medical  man  and  not  by  the  operator, 
because  the  giving  of  chloroform  to  the  surgical  degree  requires  the 
undivided  attention  of  the  administrator,  and  no  man  can  do  this  and 
operate  at  the  same  time.  I  once  learnt  an  important  lesson  on  this 
point.  I  had  occasion  to  apply  the  forceps  in  the  case  of  a  lady  who 
insisted  on  having  chloroform.  When  commencing  the  operation  I 
noticed  some  suspicious  appearances  about  the  patient,  Avho  was  a  large 
stout  Avoman,  with  a  feeble  circulation.  I  therefore  stopped,  allowed 
her  to  regain  consciousness,  and  delivered  her  without  anaesthesia, 
much  to  her  own  annoyance.  Just  one  month  after  labor  she  went  to 
a  dentist  to  have  a  tooth  extracted,  and  took  chloroform,  during  the 
inhalation  of  which  she  died.  This  impressed  on  my  mind  the  lesson 
that  no  man  can  do  two  things  at  the  same  time.  The  partial  uncon- 
sciousness of  incomplete  anaesthesia,  in  which  the  patient  is  restless  and 
tossing  about,  renders  the  application  of  forceps,  as  well  as  all  other 


ANAESTHESIA    IN    LABOR.  311 

operations,  very  difficult.  Therefore,  unless  the  patient  can  be  com- 
pletely and  fully  anaesthetized,  it  is  better  to  operate  without  chloroform 
being  given  at  all. 

[In  the  United  States  the  dangers  attending  the  use  of  chloroform 
in  obstetric  practice  have,  in  large  measure,  banished  it  from  the  lying- 
in  chamber.  Some  obstetricians  in  our  chief  cities  still  resort  to  it  with 
little  hesitation,  believing  that  by  great  carefulness  in  its  adminis- 
tration, and  by  the  substitution  of  ether  in  exceptional  cases,  all  danger 
may  be  avoided.  Others  have  a  very  great  fear  of  it,  and  universally 
trust  to  the  safer  anaesthetic.  It  is  an  error  to  suppose  that  the  par- 
turient state  robs  chloroform  of  much  of  its  danger,  the  apparent 
immunity  being  due  to  its  intermittent  and  incomplete  administration ; 
complete  anaesthesia  being  but  a  fraction  less  dangerous  than  in  surgical 
operations  upon  women  who  are  not  pregnant.  Dr.  Lusk,  already 
quoted,  after  a  large  experience  with  the  use  of  chloroform,  says : 
"Patients  in  labor  do  not  enjoy  any  absolute  immunity  from  the  pernicious 
effects  of  chloroform"1  It  is  much  to  be  regretted  that  this  more 
pleasant  anaesthetic  is  so  much  more  dangerous  than  ether  as  an 
inhalant;  but  in  consideration  of  the  difference  of  risk,  that  of  their 
relative  effects  upon  the  nose  and  trachea  is  scarcely  to  be  considered. 
Chloroform  acts  upon  the  respiratory  centres  just  as  ether  does ;  and 
this  is  an  element  of  danger  in  each,  but  is  capable  of  being  counter- 
acted by  artificial  respiration.  But,  beyond  this,  chloroform  is  far 
more  dangerous,  in  acting  upon  the  motor  ganglia  of  the  heart  and 
producing  sudden  death.  According  to  the  experiments  of  Vulpian 
upon  animals,  not  more  than  one  case  of  cardiac  failure  in  forty  can  be 
restored  by  artificial  respiration.  He  affirms  that  there  is  danger  at 
the  commencement,  during  the  course,  and  at  the  close  of  chloroformiza- 
tion,  and  even  some  hours  or  days  subsequent  to  it.  N6laton  made  the 
important  discovery  that  the  cerebral  anaemia  produced  by  chloroform, 
with  its  accompanying  death-like  condition,  might  be  remedied  by 
long  perseverance  in  artificial  respiration  with  the  patient  turned  head 
downward. 

Anaesthesia  in  labor  is  much  less  popular,  both  with  obstetricians  and 
patients  in  this  country,  than  it  was  soon  after  its  introduction.  Im- 
provements in  the  purity  of  sulphuric  ether  have  made  the  narcosis 
more  reliable,  but  the  general  effect  upon  patients  varies  very  decidedly, 
being  all  that  can  be  desired  in  some,  and  just  the  reverse  in  others. 
Some  of  the  undesirable  effects  I  have  witnessed  are  intoxication,  with 
cessation  of  labor,  hysterical  excitement,  nightmare,  and  post-partum 
inertia  and  hemorrhage.  I  have  also  witnessed  the  most  delightful 
results  from  ether  that  could  be  desired.  In  a  small,  delicate  mult- 
ipara  whose  mother  died  of  phthisis,  and  to  whom  I  had  been  obliged 
to  administer  stimulants  in  the  first  and  much  of  the  second  stage  of 
labor,  the  use  of  ether  had  the  effect  of  revolutionizing  her  condition. 
Her  pulse  became  strong  ;  her  expulsive  power  increased ;  she  had  no 
suffering ;  the  placenta  was  expelled  without  accompanying  blood ; 
and  there  was  no  subsequent  uterine  relaxation.  But  such  cases  are, 
unfortunately,  exceptional. — ED.] 

[i  Opus  cit.] 


312  LABOR. 


CHAPTEK    Y. 

PELVIC  PRESENTATIONS. 

UNDER  the  head  of  pelvic  presentations  it  is  customary  to  include  all 
cases  in  which  any  part  of  the  lower  extremities  of  the  child  presents. 
By  some  these  are  further  subdivided  into  breech,  footling,  and  knee 
presentations ;  but,  although  it  is  of  consequence  to  be  able  to  recognize 
the  feet  and  the  knee  when  they  present,  so  far  as  the  mechanism  and 
management  of  delivery  are  concerned,  the  cases  are  identical,  and, 
therefore,  may  be  most  conveniently  considered  together. 

Frequency. — Presentations  coming  under  this  head  are  far  from 
uncommon ;  those  in  which  the  breech  alone  occupies  the  pelvis  are 
met  with,  according  to  Churchill,  once  in  fifty -two  labors,  while  Rams- 
botham  estimates  that  it  presents  more  frequently,  viz.,  once  in  38.8 
labors.  Footling  presentations  occur  only  once  in  ninety-two  cases. 
They  are  probably  often  the  mere  conversion  of  original  breech  pres- 
entations, the  feet  having  come  down  during  the  labor,-  either  in  con- 
sequence of  the  sudden  escape  of  the  liquor  amnii,  when  the  breech  was 
still  freely  movable  above  the  brim,  or  from  some  other  cause.  Knee 
presentations  are  extremely  rare,  as  may  be  readily  understood  if  it  be 
borne  in  mind  that  to  admit  them  the  thighs  must  be  extended,  hence 
the  vertical  measurement  of  the  child  must  be  greatly  increased,  and 
therefore  it  could  not  be  readily  accommodated  within  the  uterine 
cavity,  unless  of  unusually  small  size.  As  a  matter  of  fact,  Mme.  La 
Chapelle  found  only  one  knee  presentation  in  upward  of  3000  cases. 

The  causes  of  pelvic  presentations  are  not  known.  They  are 
probably  the  same  as  those  which  produce  other  varieties  of  mal- 
presentation,  especially  an  excess  of  liquor  amnii  and  slight  pelvic 
contraction  ;  and  it  is  not  unlikely  that,  in  certain  women,  there  may 
be  some  peculiarity  in  the  shape  of  the  uterine  cavity  which  favors 
their  production.  It  would  be  difficult  otherwise  to  explain  such  a 
case  as  that  mentioned  by  Velpeau,  in  which  the  breech  presented  in 
six  labors. 

Prognosis. — The  results,  as  regards  the  mother,  are  in  no  way  more 
unfavorable  than  in' vertex  presentation.  The  first  stage  of  the  labor 
is  generally  tedious,  since  the  large  rounded  mass  of  the  breech  does 
.not  adapt  itself  so  well  as  the  head  to  the  lower  segment  of  the  uterus, 
and  dilatation  of  the  cervix  is  consequently  apt  to  be  retarded.  The 
second  stage  is,  however,  if  anything,  more  rapid  than  in  vertex  cases ; 
and  even  when  it  is  protracted,  the  soft  breech  does  not  produce  such 
injurious  pressure  on  the  maternal  structures  as  the  hard  and  unyield- 
ing head. 

The  result  is  very  different  as  regards  the  child.     Dubois  calculated 


PELVIC    PRESENTATIONS.  313 

that  one  out  of  eleven  children  was  stillborn.  Churchill  estimates  the 
mortality  as  much  higher,  viz.,  one  in  three  and  one-fifth.  The  latter 
certainly  indicates  a  larger  number  of  stillbirths  than  is  consistent 
with  the  experience  of  most  practitioners,  and  more  than  should  occur 
if  the  cases  be  properly  managed ;  but  there  can  be  no  doubt  that  the 
risk  to  the  child  is,  even  under  the  most  favorable  circumstances,  very 
great.  Even  when  the  child  is  .not  lost,  it  may  be  seriously  injured. 
Dr.  Huge  has  tabulated  a  series  of  twenty-nine  cases  in  which  there 
were  found  to  be  fractures  of  bones  or  other  injuries.1 

The  chief  source  of  danger  is  pressure  on  the  umbilical  cord,  in  the 
interval  elapsing  between  the  birth  of  the  body  and  the  head.  At  this 
time  the  cord  is  very  generally  compressed  between  the  head  of  the 
child  and  the  pelvic  walls,  so  that  circulation  in  its  vessels  is  arrested. 
Hence  the  aeration  of  the  foetal  blood  cannot  take  place ;  and,  pul- 
monary respiration  not  having  been  yet  established,  the  child  dies 
asphyxiated.  There  are  other  conditions  present  which  tend,  although 
in  a  minor  degree,  to  produce  the  same  result.  One  of  these  is  that 
the  placenta  is  probably  often  separated  by  the  uterine  contractions 
when  the  bulk  of  the  body  is  being  expelled,  as,  indeed,  takes  place 
under  analogous  circumstances  when  the  vertex  presents ;  the  necessary 
result  being  the  arrest  of  placental  respiration.  Joulin  thinks  that 
the  same  effect  may  be  produced  by  the  compression  of  the  placenta 
between  the  contracted  uterus  and  the  hard  mass  of  the  foetal  skull. 
Probably  all  these  causes  combine  to  arrest  the  functions  of  the  pla- 
centa ;  and,  if  the  delivery  of  the  head,  and  consequently  the  establish- 
ment of  pulmonary  respiration,  be  delayed,  the  death  of  the  child  is 
almost  inevitable.  The  corollary  is  that  the  danger  to  the  child  is  in 
direct  proportion  to  the  length  of  time  that  elapses  between  the  birth 
of  the  body  and  that  of  the  head. 

The  risk  to  the  child  is  greater  in  footling  than  in  breech  cases, 
because  in  the  former  the  maternal  structures  are  less  perfectly  dilated, 
in  consequence  of  the  small  size  of  the  feet  and  thighs,  and,  therefore, 
the  birth  of  the  head  is  more  apt  to  be  delayed. 

Diagnosis. — Inasmuch  as  the  long  axis  of  the  child  corresponds 
with  the  long  axis  of  the  uterus  in  pelvic,  as  in  vertex  presentations, 
there  is  nothing  in  the  shape  of  the  uterus  to  arouse  suspicion  as  to  the 
character  of  the  case.  Still  it  is  often  sufficiently  easy  to  recognize  a 
pelvic  presentation  by  abdominal  examination,  if  we  have  occasion  to 
make  one.  The  facility  witli  which  it  may  be  done  depends  a  good 
deal  on  the  individual  patient.  If  she  be  not  very  stout,  and  if  the 
abdominal  parietes  be  lax  and  non-resistant,  we  shall  generally  be 
able  to  feel  the  round  head  at  the  upper  part  of  the  uterus,  much  firmer 
and  more  defined  in  outline  than  the  breech.  The  conclusion  will  be 
fortified  if  we  hear  the  foetal  heart  beating  on  a  level  with,  or  above, 
the  umbilicus.  The  greater  resistance  on  one  side  of  the  abdomen  will 
also  enable  us  to  decide,  with  tolerable  accuracy,  to  which  side  the 
back  of  the  child  is  placed.  Information  thus  acquired  is,  at  the  best, 
uncertain ;  and  we  can  never  be  quite  sure  of  the  existence  of  a  pelvic 

i  Bull.  gen.  de  Therap.,  August,  1875. 


314  LABOR, 

presentation  until  we  can  corroborate  the  diagnosis  by  vaginal  exam- 
ination. 

[In  view  of  the  greater  risk  to  the  life  of  the  foetus  in  a  delivery  by 
the  breech  over  that  by  the  vertex,  it  is  advisable,  when  the  position 
is  determined  while  the  membranes  are  still  intact,  to  change  the 
presentation  from  pelvic  to  cephalic  by  external  bimanual  manipula- 
tion.— ED.] 

The  first  circumstance  to  excite  suspicion  on  examination  per 
vaginam,  even  when  the  os  is  undilated,  is  the  absence  of  the  hard 
globular  mass  felt  through  the  lower  segment  of  the  uterus,  so  charac- 
teristic of  vertex  presentations.  When  the  os  is  sufficiently  open  to 
allow  the  membranes  to  protrude,  although  the  presenting  part  is  too 
high  up  to  be  within  reach,  we  may  be  struck  with  the  peculiar  shape 
of  the  bag  of  membranes,  which,  instead  of  being  rounded,  projects  a 
considerable  distance  through  the  os,  like  the  finger  of  a  glove.  This 
is  a  peculiarity  met  with  in  all  malpresentations  alike,  and  is,  indeed, 
much  less  distinct  in  breech  than  in  footling  presentations,  because  in 
the  former  the  membranes  are  more  stretched,  just  as  they  are  in  vertex 
cases.  When  the  membranes  rupture,  instead  of  the  waters  dribbling 
away  by  degrees,  they  often  escape  with  a  rush,  in  consequence  of  the 
pelvic  extremity  not  filling  up  the  lower  part  of  the  uterus  so  accu- 
rately as  the  head,  which  acts  as  a  sort  of  ball-valve,  and  prevents  the 
sudden  and  complete  discharge  of  the  waters. 

Often  on  first  examining,  even  when  the  membranes  are  ruptured, 
the  presentation  is  too  high  up  to  be  made  out  accurately.  All  that 
we  can  be  certain  of  is,  that  it  is  not  the  head  ;  and  the  case  must  be 
carefully  watched,  and  examinations  frequently  repeated,  until  the 
precise  nature  of  the  presentation  can  be  established.  If  the  breech 
present,  the  finger  first  impinges  on  a  round,  soft  prominence,  on 
depressing  which  a  bony  protuberance,  the  tuber  ischii,  can  be  felt. 
On  passing  the  finger  upward  it  reaches  a  groove  beyond  which  a 
similar  fleshy  mass,  the  other  buttock,  can  be  felt.  In  this  groove 
various  characteristic  points,  diagnostic  of  the  presentation,  can  be 
made  out.  Toward  one  end  we  can  feel  the  movable  tip  of  the  coccyx, 
and  above  it  the  hard  sacrum,  with  its  rough  projecting  prominences. 
These  points,  if  accurately  made  out,  are  quite  characteristic,  and  re- 
semble nothing  in  any  other  presentation.  In  front  there  is  the  anus, 
in  which  it  is  sometimes,  but  by  no  means  always,  possible  to  insert 
the  tip  of  the  finger.  If  this  can  be  done,  it  is  easy  to  distinguis'  it 
from  the  mouth,  with  which  it  might  be  confounded,  by  observing 
that  the  hard  alveolar  ridges  are  not  contained  within  it.  Still  more 
in  front  we  may  find  the  genital  organs,  the  scrotum  in  male  children 
being  often  much  swollen  if  the  labor  has  been  protracted.  Thus  it  is 
often  possible  to  recognize  the  sex  of  the  child  before  birth. 

The  breech  might  be  mistaken  for  the  face,  especially  if  the  latter 
be  much  swollen  ;  but  this  mistake  can  readily  be  avoided  by  feeling 
the  spinous  processes  of  the  sacrum. 

The  knee  is  recognized  by  its  having  two  tuberosities  with  a  depres- 
sion between  them.  It  might  be  confounded  with  the  heel,  the  elbow, 
or  the  shoulder.  From  the  heel  it  is  distinguished  by  having  two 


PELVIC    PRESENTATIONS.  315 

tuberosities  instead  of  one ;  from  the  elbow,  by  the  latter  having  one 
sharp  tuberosity,  with  a  depression  on  one  side,  instead  of  a  central 
depression  and  two  lateral  prominences ;  and  from  the  shoulder,  by 
the  latter  being  more  rounded,  having  only  one  prominence,  running 
from  which  the  acromion  and  clavicle  can  be  traced. 

The  foot  may  be  mistaken  for  the  hand.  This  error  will  be  avoided 
by  remembering  that  all  the  toes  are  in  the  same  line,  and  that  the 
great  toe  cannot  be  brought  into  apposition  with  the  others,  as  the 
thumb  can  with  the  fingers.  The  internal  border  of  the  foot  is  much 
thicker  than  the  external,  whereas  the  two  borders  of  the  hand  are  of 
the  same  thickness.  Moreover,  the  foot  is  articulated  at  right  angles 
to  the  leg,  and  cannot  be  brought  into  a  line  with  it,  as  the  hand  can 
with  the  arm.  Finally,  the  projection  of  the  calcaneum  is  character- 
istic, and  resembles  nothing  in  the  hand. 

Mechanism. — As  is  the  case  in  other  presentations,  obstetricians 
have  very  variously  subdivided  breech  presentations,  Avith  the  effect  of 
needlessly  complicating  the  subject.  The  simplest  division,  and  that 
which  will  most  readily  impress  itself  on  the  memory  of  the  student, 
is  to  describe  the  breech  as  presenting  in  four  positions,  analogous  to 
those  of  the  vertex,  the  sacrum  being  taken  as  representing  the  occiput, 
and  the  positions  being  numbered  according  to  the  part  of  the  pelvis 
to  which  it  points.  Thus  we  have — 

First,  or  left  sacro-anterior  (sacro-laeva  anterior,  S.L.A.,  correspond- 
ing to  the  first  position  of  the  vertex).  The  sacrum  of  the  child  points 
to  the  left  foramen  ovale  of  the  mother. 

Second,  or  right  sacro-anterior  (sacro-dextra  anterior,  S.D.A.,  corre- 
sponding to  the  second  vertex  position).  The  sacrum  of  the  child 
points  to  the  right  foramen  ovale  of  the  mother. 

Third,  or  right  sacro-poslerior  (sacro-dextra  posterior,  S.D.P.,  corre- 
sponding to  the  third  vertex  position).  The  sacrum  of  the  child  points 
to  the  right  sacro-iliac  synchondrosis  of  the  mother. 

Fourth,  or  left  sacro-posterior  (sacro-lseva  posterior,  S.L.P.,  corre- 
sponding to  the  fourth  vertex  position).  The  sacrum  of  the  child 
points  to  the  left  sacro-iliac  synchondrosis  of  the  mother. 

Of  these,  as  with  the  corresponding  vertex  positions,  the  first  (s.L.A.) 
and  third  (S.D.P.)  are  the  most  common,  their  comparative  frequency, 
no  doubt,  depending  on  the  same  causes.  The  mechanical  conditions 
to  which  the  presenting  part  is  subjected  are  also  identical,  but  the 
alterations  of  position  of  the  breech  in  its  progress  are  by  no  means  so 
uniform  as  those  of  the  head,  on  account  of  its  less  perfect  adaptation 
to  the  pelvic  cavity.  The  mechanism  of  the  delivery  of  the  shoulders 
and  head  in  breech  presentations,  moreover,  is  of  much  greater  prac- 
tical importance  than  that  of  the  body  in  vertex  presentations,  inas- 
much as  the  safety  of  the  child  depends  on  its  speedy  and  satisfactory 
accomplishment.  Bearing  these  facts  in  mind,  it  will  suffice  to  describe 
briefly  the  phenomena  of  delivery  in  the  first  (S.L.A.)  and  third  (S.D.P.) 
breech  positions. 

Position  of  the  Child  at  Brim. — In  the  first  position  (s.L.A.)  (Fig. 
113)  the  sacrum  of  the  child  points  to  the  left  foramen  ovale;  its  back 
is  consequently  placed  to  the  left  side  of  the  uterus  and  anteriorly,  and 


316 


LABOR 


its  abdomen  looks  to  the  right  side  of  the  uterus  and  posteriorly.  The 
sulcus  between  the  buttocks  lies  in  the  right  oblique  diameter  of  the 
pelvis,  while  the  transverse  diameter  of  the  buttocks  lies  in  the  left 
oblique  diameter,  the  left  buttock  being  most  easily  within  reach.  As 
in  vertex  presentations,  the  hips  of  the  child  lie  on  the  same  level  at  the 
pelvic  brim,  although  Naegele  describes  the  left  hip  as  placed  lower 
than  the  right. 


FIG.  113. 


First,  or  left  sacro-anterior  position  (S.L.A.)  of  the  breech. 

As  the  pains  act  on  the  body  of  the  child,  the  breech  is  gradually 
forced  through  the  pelvic  cavity,  retaining  the  same  relations  as  at  the 
brim,  its  progress  being  generally  more  slow  than  that  of  the  head, 
until  it  reaches  the  lower  pelvic  strait,  when  the  same  mechanism  which 
produces  rotation  of  the  occiput  comes  to  operate  upon  it.  The  result 
is  a  rotation  of  the  child's  pelvis,  so  that  its  transverse  diameter  comes 
to  lie  approximately  in  the  antero-posterior  diameter  of  the  outlet,  its 
antero-posterior  diameter  corresponds  to  the  transverse  diameter  of  the 
mother's  pelvis,  the  left  hip  lies  behind  the  pubes,  and  the  right  toward 
the  sacrum.  This  rotation,  which  is  admitted  by  the  majority  of  obste- 
tricians, is  altogether  denied  by  Naegele.  There  can  be  no  doubt, 
however,  that  it  does  generally  take  place,  but  by  no  means  so  con- 
stantly as  the  corresponding  rotation  of  the  vertex;  and  it  is  not 
uncommon  for  it  to  be  entirely  absent,  and  for  the  hips  to  be  born  in 
the  oblique  diameter  of  the  outlet.  The  body  of  the  child  is  said  fre- 
quently not  to  follow  the  movement  imparted  to  the  hips,  so  that  there 
is  more  or  less  of  a  twist  in  the  vertebral  column. 

The  left  hip  now  becomes  firmly  fixed  behind  the  pubes,  and  a 
movement  of  extension,  analogous  to  that  of  the  head  in  vertex  pres- 
entations, takes  place.  The  right,  or  posterior,  hip  revolves  around 
the  fixed  one,  gradually  distends  the  perineum,  and  is  expelled  first, 


PELVIC    PRESENTATIONS.  317 

the  left  hip  rapidly  following.  As  soon  as  both  hips  are  born,  the  feet 
slip  out,  unless  the  legs  are  completely  extended  upon  the  child's  abdo- 
men. The  shoulders  soon  follow,  lying  in  the  left  oblique  diameter 
of  the  pelvis  (Fig.  114).1  The  left  shoulder  rotates  forward  behind 
the  pubes,  where  it  becomes  fixed,  the  right  shoulder  sweeping  over 
the  perineum,  and  being  born  first.  The  arms  of  the  child  are  gener- 
ally found  placed  upon  its  thorax,  and  are  born  before  the  shoulders. 
Sometimes  they  are  extended  over  the  child's  head,  thus  causing  con- 
siderable delay,  and  greatly  increasing  the  risk  to  the  child.  It  is 
now  generally  admitted  that  such  extension  is  most  apt  to  occur  when 
traction  has  been  made  on  the  child's  body  with  the  view  of  hastening 
delivery,  and  that  it  is  rarely  met  with  when  the  expulsion  of  the  body 
is  left  entirely  to  the  normal  powers. 


FIG.  114. 


Passage  of  the  shoulders  and  partial  rotation  of  the  thorax. 

Delivery  of  the  Head. — "When  the  shoulders  are  expelled  the  head 
enters  the  pelvis  in  the  opposite,  or  right  oblique  diameter,  the  face 
looking  to  the  right  sacro-iliac  synchondrosis.  As  the  greater  part  of 
the  child  is  now  expelled,  and  as  the  head  has  entered  the  vagina,  the 
uterus,  having  a  comparatively  small  mass  to  contract  upon,  must 
obviously  act  at  a  mechanical  disadvantage.  Still  the  pressure  of  the 
head  on  the  vagina  is  a  powerful  inciter,  the  accessory  muscles  of 
parturition  are  brought  into  strong  action,  and  there  may  be  sufficient 
force  to  insure  expulsion  of  the  head  without  artificial  aid.  On  account 
of  the  great  resistance  to  the  descent  of  the  occiput  from  its  articula- 
tion with  the  spinal  column,  the  pains  have  the  effect  of  forcing  down 
the  anterior  portion  of  the  head,  and  this  insures  the  complete  flexion 
of  the  chin  upon  the  sternum  (Fig.  115).  This  is  a  great  advantage 
from  a  mechanical  point  of  view,  as  it  causes  the  short  occipito-frontal 
diameter  of  the  head  to  enter  the  pelvis  in  the  axis  of  the  uterus  and 
the  brim.  If  the  head  should  be  in  a  state  of  partial  extension — as 
sometimes  happens  when  the  pelvis  is  unusually  roomy — the  occipito- 
mental  diameter  is  placed  in  a  similar  relation  to  the  brim,  a  position 
certainly  less  iavorable  to  the  easy  birth  of  the  head.  As  the  head 

1  This  figure,  however,  represents  the  position  of  the  shoulders  in  the  second  (S.D.A.)  position ) 


318  LABOR. 

descends  it  experiences  a  movement  of  rotation,  the  occiput  passing 
forward  and  to  the  right,  behind  the  pubic  arch,  the  face  turning 
backward  into  the  hollow  of  the  sacrum.  The  body  of  the  child  will 
be  observed  to  follow  this  movement,  so  that  its  back  is  turned  toward 
the  mother's  abdomen,  its  anterior  surface  to  the  perineum.  The  nape 
of  the  neck  now  becomes  firmly  fixed  under  the  arch  of  the  pubes,  the 
pains  act  chiefly  on  the  anterior  portion  of  the  head,  and  cause  it  to 
sweep  over  the  perineum,  the  chin  being  first  born,  then  the  mouth 
and  forehead,  and  lastly  the  occiput. 


FIG.  us. 


Descent  of  the  head. 

It  is  needless  to  describe  the  differences  between  the  mechanism  of 
the  second  (S.D.A.)  and  first  (S.L.A.)  positions,  which  the  student  who 
has  mastered  the  subject  of  vertex  presentations  will  readily  under- 
stand. It  is  necessary,  however,  to  say  a  few  words  as  to  sacro- 
posterior  positions,  choosing  for  that  purpose  the  third  (S.D.P.),  which 
is  the  more  common  of  the  two.  This  is  exactly  the  opposite  of  the 
first  (S.L.A.)  position.  The  sacrum  of  the  child  points  to  the  right 
sacro-iliac  synchondrosis,  its  abdomen  looks  forward  and  to  the  left 
side  of  the  mother.  The  transverse  diameter  of  the  child's  pelvis  lies 
in  the  left  oblique  diameter,  the  right  hip  being  anterior.  The  birth 
of  the  body  generally  takes  place  exactly  in  the  way  that  has  been 
already  described,  the  right  hip  being  toward  the  pubes. 

As  the  head  descends  into  the  pelvis  the  occiput  most  usually  rotates 
along  its  right  side — the  rotation  having  been  often  already  partially 
effected  when  that  of  the  hips  had  been  made — until  it  comes  to  rest 
behind  the  pubes,  the  face  passing  backward  along  the  left  side  of  the 
pelvis  into  the  hollow  of  the  sacrum.  This  change  corresponds  exactly 
to  the  anterior  rotation  of  the  occiput  in  occipito-posterior  positions, 
and  is  the  natural  and  favorable  termination. 

Sometimes,  further  rotation  does  not  take  place,  and  the  occiput 
then  turns  backward  into  the  hollow  of  the  sacrum.  What  then 
generally  occurs  is,  that  the  pains  continue,  for  the  reason  already 
mentioned,  to  depress  the  chin  and  produce  strong  flexion  of  the  face 
on  the  sternum,  the  occiput  becoming  fixed  on  the  anterior  border  of 


PELVIC    PRESENTATIONS.  319 

the  perineum.  The  pains  continuing  to  act  chiefly  on  the  anterior 
part  of  the  head,  the  face  is  borne  first  behind  the  pubes,  the  occiput 
only  slipping  over  the  perineum  after  the  forehead  has  been  ex- 
pelled. 

The  second  mode  of  termination  of  such  positions  is  mentioned  in 
most  works,  on  the  authority  of  one  or  two  recorded  cases ;  but 
although  mechanically  possible,  it  is  certainly  an  event  of  extreme 
rarity.  The  chin,  instead  of  being  flexed  on  the  sternum,  is  greatly 
extended,  so  that  the  face  of  the  child  looks  upward  toward  the  pelvic 
brim.  The  chin  then  hitches  over  the  upper  edge  of  the  pubes  and 
becomes  fixed  there,  while  the  force  of  the  uterine  contractions  is  ex- 
pended oil  the  posterior  part  of  the  head,  which  descends  through  the 
pelvis,  distending  the  perineum,  and  is  born  first,  the  face  subsequently 
following. 

The  mechanism  of  the  delivery  of  the  body  and  head  in  cases  in 
which  the  feet  originally  present  does  not  differ,  in  any  important 
respect,  from  that  which  has  been  already  described,  and  requires  no 
separate  notice. 

Treatment. — From  what  has  been  said  of  the  natural  mechanism, 
it  is  evident  that  one  of  the  most  fruitful  causes  of  difficulty  and  com- 
plication is  undue  interference  on  the  part  of  the  practitioner.  It  is, 
no  doubt,  tempting  to  use  traction  on  the  partially  born  trunk  in  the 
hope  of  expediting  delivery ;  but  when  it  is  remembered  that  this  is 
almost  certain  to  produce  extension  of  the  arms  above  the  head,  and 
subsequently  extension  of  the  occiput  on  the  spine,  both  of  which 
seriously  increase  the  difficulty  of  delivery,  the  necessity  of  leaving 
the  case  as  much  as  possible  to  Nature  will  be  apparent. 

Having  once,  therefore,  determined  the  existence  of  a  pelvic  pres- 
entation, nothing  more  should  be  done  until  the  birth  of  the  breech. 
The  membranes  should  be  even  more  carefully  prevented  from  prema- 
turely rupturing  than  in  vertex  presentations,  since  they  serve  to  dilate 
the  genital  passages  better  than  does  the  presenting  part.  Hence  they 
should  be  preserved  intact,  if  possible,  until  they  reach  the  floor  of  the 
pelvis,  instead  of  being  punctured  as  soon  as  the  os  is  fully  dilated. 
The  breech  when  born  should  be  received  and  supported  in  the  palm 
of  the  hand. 

When  the  body  is  expelled  as  far  as  the  umbilicus,  the  dangers  to 
the  child  commence ;  for  now  the  cord  is  apt  to  be  pressed  between 
the  body  of  the  child  and  the  pelvic  walls.  To  obviate  this  risk  as 
much  as  possible,  a  loop  of  the  cord  should  be  pulled  down,  and  car- 
ried to  that  part  of  the  pelvis  where  there  is  most  room,  which  will 
generally  be  opposite  one  or  the  other  sacro-iliac  synchondrosis.  As 
long  as  the  cord  is  freely  pulsating  we  may  be  satisfied  that  the  life  of 
the  child  is  not  gravely  imperilled,  although  delay  is  fraught  with 
danger  from  other  sources  which  have  been  already  indicated.  In 
most  cases  the  arms  now  slip  out ;  but  it  may  happen,  even  without 
any  fault  on  the  part  of  the  accoucheur,  that  they  are  extended  above 
the  head,  and  it  is  of  great  importance  that  we  should  be  thoroughly 
acquainted  with  the  best  means  of  liberating  them  from  their  abnormal 
position. 


320  LABOR. 

They  must,  of  course,  never  be  drawn  directly  downward,  or  the 
almost  certain  result  would  be  fracture  of  the  fragile  bones.  We 
should  endeavor  to  make  the  arm  sweep  over  the  lace  and  chest  of 
the  child,  so  that  the  natural  movements  of  its  joints  should  not  be 
opposed.  If  the  shoulders  be  within  easy  reach,  the  finger  of  the 
accoucheur  should  be  slipped  over  that  which  is  posterior — because 
there  is  likely  to  be  more  space  for  this  manoeuvre  toward  the  sacrum 
— and  gently  carried  downward  toward  the  elbow,  which  is  drawn 
over  the  face,  and  then  onward,  so  as  to  liberate  the  forearm.  The 
same  manoeuvre  should  then  be  applied  to  the  opposite  arm.  It  may 
be  that  the  fhoulders  are  not  easily  reached,  and  then  they  may  be 
depressed  by  altering  the  position  of  the  child's  body.  If  this  be 
carried  well  up  to  the  mother's  abdomen,  the  posterior  shoulder  will 
be  brought  lower  down ;  and,  by  reversing  this  procedure  and  carry- 
ing the  body  back  over  the  perineum,  the  anterior  shoulder  may  be 
similarly  depressed.  It  is  only  very  exceptionally,  however,  that  these 
expedients  are  required. 

Birth  of  the  Head. — The  arms  being  extracted,  some  degree  of 
artificial  assistance  is,  at  this  time,  almost  always  required.  If  there 
be  much  delay,  the  child  will  almost  certainly  perish.  Attempts  have 
been  made,  in  cases  in  which  delivery  of  the  head  could  not  be  rapidly 
eifected,  to  establish  pulmonary  respiration  by  passing  one  or  two 
fingers  into  the  vagina,  so  as  to  press  it  back  and  admit  air  to  the 
child's  mouth,  or  by  passing  a  catheter  or  tube  into  the  mouth.  Neither 
of  these  expedients  is  reliable,  and  we  should  rather  seek  to  aid  Nature 
in  completing  the  birth  of  the  head  as  rapidly  as  possible.  The  first 
thing  to  do,  supposing  the  face  to  have  rotated  into  the  cavity  of  the 
sacrum,  is  to  carry  the  body  of  the  child  well  up  toward  the  pubes 
and  abdomen  of  the  mother  without  applying  any  traction  for  fear  of 
interfering  with  the  all-important  flexion  of  the  chin  on  the  sternum. 

If  now  the  patient  bear  down  strongly,  the  natural  powers  may  be 
sufficient  to  complete  delivery.  If  there  be  any  delay,  traction  must 
be  resorted  to,  and  we  must  endeavor  to  apply  it  in  such  a  way  as  to 
insure  flexion.  For  this  purpose,  while  the  body  of  the  child  is 
grasped  by  the  left  hand,  and  drawn  upward  toward  the  mother's 
abdomen,  the  index  and  middle  fingers  of  the  right  hand  are  placed 
on  the  back  of  the  child's  neck,  so  that  their  tips  press  on  either  side 
of  the  base  of  the  occiput,  and  push  the  head  into  a  state  of  flexion. 
In  most  works  we  are  advised  to  pass  the  index  and  middle  fingers  of 
the  left  hand  at  the  same  time  over  the  child's  face,  so  as  to  depress 
the  superior  maxilla.  Dr.  Barnes  insists  that  this  is  quite  unnecessary, 
and  that  extraction  in  the  manner  indicated,  by  pressure  on  the  occiput, 
is  quite  sufficient.  Should  it  not  prove  so,  flexion  of  the  chin  may  be 
very  effectually  assisted  by  downward  pressure  on  the  forehead  through 
the  rectum.  One  or  two  fingers  of  the  left  hand  can  readily  be  inserted 
into  the  bowel,  and  the  expulsion  of  the  head  -is  thus  materially 
facilitated. 

By  far  the  most  powerful  aid,  however,  in  hastening  delivery  of  the 
head,  should  delay  occur,  is  pressure  from  above.  This  has  been, 
strangely  enough,  almost  altogether  omitted  by  writers  on  the  subject. 


PELVIC    PRESENTATIONS.  321 

It  has  been  strongly  recommended  by  Professor  Penrose,  and  there 
can  be  no  question  of  its  utility.  Indeed,  as  the  uterus  contracts 
tightly  around  the  head,  uterine  expression  can  be  applied  almost 
directly  to  the  head  itself,  and  without  any  fear  of  deranging  its 
proper  relation  to  the  maternal  passages.  It  is  very  seldom  indeed 
that  a  judicious  combination  of  traction  on  the  part  of  the  accoucheur, 
with  firm  pressure  through  the  abdomen  applied  by  an  assistant,  will 
fail  in  effecting  delivery  of  the  head  before  the  delay  has  had  time  to 
prove  injurious  to  the  child. 

Application  of  the  Forceps  to  the  After-coming-  Head. — Many 
accoucheurs — among  others,  Meigs  and  Rigby — advocate  the  applica- 
tion of  the  forceps  when  there  is  delay  in  the  birth  of  the  after-coming 
head.  If  the  delay  be  due  to  want  of  expulsive  force  in  a  pelvis  of 
normal  size,  manual  extraction,  in  the  manner  just  described,  will  be 
found  to  be  sufficient  in  almost  every  case,  and  preferable,  as  being 
more  rapid,  easier  of  execution,  and  safer  to  the  child.  The  forceps 
may  be  quite  properly  tried,  if  other  means  have  failed;  especially  if 
there  be  some  disproportion  between  the  size  of  the  head  and  the 
pelvis. 

Difficulties  in  delivery  may  also  occur  in  sacro-posterior  positions. 
Up  to  the  time  of  the  birth  of  the  head  the  labor  usually  progresses  as 
readily  as  in  the  sacro-anterior  positions.  If  the  forward  rotation  of 
the  hips  do  not  take  place,  much  subsequent  difficulty  may  be  pre- 
vented by  gently  favoring  it  by  traction  applied  to  the  breech  during 
the  pains,  the  finger  being  passed  for  this  purpose  into  the  fold  of  the 
groin. 

It  is  after  the  birth  of  the  shoulders  that  the  absence  of  rotation  is 
most  likely  to  prove  troublesome.  It  has  been  recommended  that  the 
body  should  then  be  grasped,  in  the  interval  between  the  pains,  and 
twisted  around  so  as  to  bring  the  occiput  forward.  It  is  by  no  means 
certain,  however,  that  the  head  would  follow  the  movement  imparted 
to  the  body,  and  there  must  be  a  serious  danger  of  giving  a  fatal  twist 
of  the  neck  by  such  a  manoeuvre.  The  better  plan  is  to  direct  the 
face  backward,  toward  the  cavity  of  the  sacrum,  by  pressing  on  the 
anterior  temple  during  the  continuance  of  a  pain.  In  this  way  the 
proper  rotation  will  generally  be  effected  without  much  difficulty,  and 
the  case  will  terminate  in  the  usual  way. 

If  rotation  of  the  occiput  forward  do  not  occur,  it  is  necessary  for 
the  practitioner  to  bear  in  mind  the  natural  mechanism  of  delivery 
under  such  circumstances.  In  the  majority  of  cases  the  proper  plan  is 
to  favor  flexion  of  the  chin  by  upward  pressure  on  the  occiput,  and  to 
exert  traction  directly  backward,  remembering  that  the  nape  of  the 
neck  should  be  fixed  against  the  anterior  margin  of  the  perineum.  If 
this  be  not  remembered,  and  traction  be  made  in  the  axis  of  the  pelvic 
outlet,  the  delivery  of  the  head  will  be  seriously  impeded.  In  the  rare 
cases  in  which  the  head  becomes  extended,  and  the  chin  hitches  on  the 
upper  margin  of  the  pubes,  traction  directly  forward  and  upward  may 
be  required  to  deliver  the  head  ;  but  before  resorting  to  it  care  should  be 
taken  to  ascertain  that  backward  extension  of  the  head  has  really 
taken  place. 

21 


322  LABOR. 

It  remains  for  us  to  consider  the  measures  which  may  be  adopted  in 
those  troublesome  cases  in  which  the  breech  refuses  to  descend,  and 
becomes  impacted  in  the  pelvic  cavity,  either  from  uterine  inertia,  or 
from  disproportion  between  the  breech  and  the  pelvis.  The  peculiar 
shape  of  the  presenting  part  unfortunately  renders  such  cases  very 
difficult  to  manage. 

Three  measures  have  been  chiefly  employed :  1st,  the  forceps ; 
2d,  bringing  down  one  or  both  feet,  so  as  to  break  up  the  presenting 
part,  and  convert  it  into  a  footling  case ;  3d,  traction  on  the  breech, 
either  by  the  fingers,  a  blunt  hook,  or  fillet  passed  over  the  groin. 

Forceps. — The  forceps  has  generally  been  considered  unsuited  for 
breech  cases  in  consequence  of  its  construction  to  fit  the  foetal  head, 
which  renders  it  liable  to  slip  when  applied  to  the  breech.  The  objec- 
tion, probably  to  a  great  extent  true  with  reference  to  most  forceps, 
seems  not  to  hold  good  when  the  axis-traction  forceps  of  Tarnier  or 
Simpson  is  used.  Lusk  strongly  recommends  it,  and  Harvey,  of 
Calcutta,  has  published  six  consecutive  cases  in  which  he  employed 
this  method  of  delivery,  in  three  with  complete  success.  Truzzi,1  who 
has  written  strongly  in  favor  of  the  forceps  in  difficult  breech  cases, 
prefers  it  greatly  to  traction  either  by  the  fingers  or  the  fillet  when  the 
breech  is  high  in  the  pelvis,  and  recommends  that,  in  order  to  secure 
a  strong  hold,  the  blades  should  be  passed  so  that  their  extremities 
extend  above  the  crests  of  the  foetal  ilia.  I  have  only  used  it  myself 
in  one  or  two  cases,  but  in  these  the  results  were  extremely  good,  and 
delivery  was  effected  with  a  facility  which  surprised  me,  and  I  can  see 
no  objection  to  a  cautious  trial  of  the  instrument.  [A  better-fitting 
instrument  is  the  special  breech-forceps,  with  oval  fenestras,  flat-edged 
blades,  and  long  superimposed  shanks,  modelled  to  fit  the  sides  of  the 
breech  over  the  trochanters  and  ilia. — ED.] 

Bringing  Down  a  Foot. — Barnes  insists  on  the  superiority  of  the 
second  plan,  and  there  can  be  no  question  that,  if  a  foot  can  be  got 
down,  the  accoucheur  has  a  complete  control  over  the  progress  of  the 
labor  which  he  can  gain  in  no  other  way.  If  the  breech  be  arrestd  at 
or  near  the  brim,  there  will  generally  be  no  great  difficulty  in  effecting 
the  desired  object.  It  will  be  necessary  to  give  chloroform  to  the 
extent  of  complete  anaesthesia,  and  to  pass  the  hand  over  the  child's 
abdomen  in  the  same  manner,  and  with  the  same  precautions,  as  in 
performing  podalic  version,  until  a  foot  is  reached,  which  is  seized 
and  pulled  down.  If  the  feet  be  placed  in  the  usual  way  close  to  the 
buttocks,  no  great  difficulty  is  likely  to  be  experienced.  If,  however, 
the  legs  be  extended  on  the  abdomen,  it  will  be  necessary  to  introduce 
the  hand  and  arm  very  deeply,  even  ui  to  the  fund  us  of  the  uterus,  a 
procedure  which  is  always  difficult,  and  which  may  be  very  hazardous. 
Nor  do  I  think  that  the  attempt  to  bring  down  the  feet  can  be  safe 
when  the  breech  is  low  down  and  fixed  in  the  pelvic  cavity.  A  cer- 
tain amount  of  repression  of  the  breech  is  possible,  but  it  is  evident  that 
this  cannot  be  safely  attempted  when  the  breech  is  at  all  low  down. 

Traction  on  the  Groin. — Under  such  circumstances  traction  is  our 

i  Gaz.  Med.  Ital.  Lomb.,  August,  1883. 


PRESENTATIONS    OF    THE    FACE.  323 

only  resource,  and  this  is  always  difficult  and  often  unsatisfactory.  Of 
all  contrivances  for  this  purpose  none  is  better  than  the  hand  of  the 
accoucheur.  The  index  finger  can  generally  be  slipped  over  the  groin 
without  difficulty,  and  traction  can  be  applied  during  the  pains.  Fail- 
ing this,  or  when  it  proves  insufficient,  an  attempt  should  be  made  to 
pass  a  fillet  over  the  groins.  A  soft  silk  handkerchief,  or  a  skein  of 
worsted,  answers  best,  but  it  is  by  no  means  easy  to  apply.  The  sim- 
plest plan,  and  one  which  is  far  better  than  the  expensive  instruments 
contrived  for  the  purpose,  is  to  take  a  stout  piece  of  copper  wire  and 
bend  it  double  into  the  form  of  a  hook.  The  extremity  of  this  can 
generally  be  guided  over  the  hips,  and  through  its  looped  end  the 
fillet  is  passed.  The  wire  is  now  withdrawn,  and  carries  the  fillet 
over  the  groins.  I  have  found  this  simple  contrivance,  which  can  be 
manufactured  in  a  few  moments,  very  useful,  and  by  means  of  such  a 
fillet  very  considerable  tractive  force  can  be  employed.  The  use  of  a 
soft  fillet  is  in  every  way  preferable  to  the  blunt  hook  which  is  con- 
tained in  most  obstetric  bags.  A  hard  instrument  of  this  kind  is 
quite  as  difficult  to  apply,  and  any  strong  traction  employed  by  it  is 
almost  certain  to  seriously  injure  the  delicate  foetal  structures  over 
which  it  is  placed.  As  an  auxiliary  the  employment  of  uterine 
expression  should  not  be  forgotten,  since  it  may  give  material  aid 
when  the  difficulty  is  only  due  to  uterine  inertia. 

Embryotomy . — Failing  all  endeavors  to  deliver  by  these  expedients, 
there  is  no  resource  left  but  to  break  up  the  presenting  part  by  scissors, 
or  by  craniotomy  instruments ;  but  fortunately  so  extreme  a  measure 
is  but  rarely  necessary. 

Examination  of  the  Child. — After  a  difficult  breech  labor  is  com- 
pleted the  child  should  be  carefully  examined  to  see  that  the  bones  of 
the  thighs  and  arms  have  not  been  injured.  Fractures  of  the  thigh 
are  far  from  uncommon  in  such  cases,  and  the  soft  bones  of  the  newly 
born  child  will  readily  and  rapidly  unite  if  placed  at  once  in  proper 
splints. 


CHAPTER   YI. 

PRESENTATIONS  OF  THE  FACE. 

Presentations  of  the  face  are  by  no  means  rare ;  and,  although  in 
the  great  majority  of  cases  they  terminate  satisfactorily  by  the  un- 
assisted powers  of  Nature,  yet  every  now  and  again  they  give  rise  to 
much  difficulty,  and  then  they  may  be  justly  said  to  be  amongst  the 
most  formidable  of  obstetric  complications.  It  is,  therefore,  essential 
that  the  practitioner  should  thoroughly  understand  the  natural  history 
of  this  variety  of  presentation,  with  the  view  of  enabling  him  to 
intervene  with  the  best  prospect  of  success. 


324  LABOR. 

The  older  accoucheurs  had  very  erroneous  views  as  to  the  mechanism 
and  treatment  of  these  cases,  most  of  them  believing  that  delivery  was 
impossible  by  the  natural  efforts,  and  that  it  was  necessary  to  inter- 
vene by  version  in  order  to  eifect  delivery.  Smellie  recognized  the 
fact  that  spontaneous  delivery  is  possible,  and  that  the  chin  turns  for- 
ward and  under  the  pubes  ;  but  it  was  not  until  long  after  his  time, 
and  chiefly  after  the  appearance  of  Mme.  La  Chapelle's  essay  on  the 
subject,  that  the  fact  that  most  cases  could  be  naturally  delivered  was 
fully  admitted  and  acted  upon. 

Frequency. — The  frequency  of  face  presentations  varies  curiously 
in  different  countries.  Thus,  Collins  found  that  in  the  Rotunda 
Hospital  there  was  only  1  case  in  497  labors,  although  Churchill  gives 
1  in  249  as  the  average  frequency  in  British  practice ;  while  in 
Germany  this  presentation  is  met  with  once  in  169  labors.  The  only 
reasonable  explanation  of  this  remarkable  difference  is,  that  the  dorsal 
decubitus,  generally  followed  on  the  Continent,  favors  the  transforma- 
tion of  vertex  presentations  into  those  of  the  face. 

The  mode  in  which  this  change  is  effected — for  it  can  hardly  be 
doubted  that,  in  the  large  majority  of  cases,  face  presentation  is  due 
to  a  backward  displacement  of  the  occiput  after  labor  has  actually 
commenced,  but  before  the  head  has  engaged  in  the  brim — has  been 
made  the  subject  of  various  explanations. 

It  has  generally  been  supposed  that  the  change  is  induced  by  a 
hitching  of  the  occiput  on  the  brim  of  the  pelvis,  so  as  to  produce 
extension  of  the  head,  and  descent  of  the  face ;  the  occurrence  being 
favored  by  the  oblique  position  of  the  uterus  so  frequently  met  with 
in  pregnancy.  Hecker1  attaches  considerable  importance  to  a  pecu- 
liarity in  the  shape  of  the  foetal  head  generally  observed  in  face  pres- 
entations, the  cranium  having  the  dolicho-cephalous  form,  prominent 
posteriorly,  with  the  occciput  projecting,  which  has  the  effect  of  in- 
creasing the  length  of  the  posterior  cranial  lever  arm,  and  facilitating 
extension  when  circumstances  favoring  it  are  in  action.  Dr.  Duncan2 
thinks  that  uterine  obliquity  has  much  influence  in  the  production  of 
face  presentation,  but  in  a  different  way  to  that  above  referred  to.  He 
points  out  that,  when  obliquity  is  very  marked,  a  curve  in  the  genital 
passages  is  produced,  the  convexity  of  which  is  directed  to  the  side 
toward  which  the  uterus  is  deflected.  When  uterine  contraction  com- 
mences, the  foetus  is  propelled  downward,  and  the  part  corresponding 
to  the  concavity  of  the  curve  is  acted  on  to  the  greatest  advantage  by 
the  propelling  force,  and  tends  to  descend.  Should  the  occiput  happen 
to  lie  in  the  convexity  of  the  curve  so  formed,  the  tendency  will  be 
for  the  forehead  to  descend.  In  the  majority  of  cases  its  descent  will 
be  prevented  by  the  increased  resistance  it  meets  with,  in  consequence 
of  the  greater  length  of  the  anterior  cranial  lever  arm  ;  but,  if  the 
uterine  obliquity  be  extreme,  this  may  be  counterbalanced,  and  a  face 
presentation  ensues.  The  influence  of  this  obliquity  is  corroborated 
by  the  observation  of  Baudelocque,  that  the  occiput  in  face  presenta- 
tions almost  invariably  corresponds  to  the  side  of  the  uterine  obliquity. 

1  Ueber  die  Schadelform  bei  Gesichtslagen. 
*  Edin.  Med.  Journ.,  vol.  xv. 


PRESENTATIONS    OF    THE    FACE.  325 

A  further  corroboration  is  afforded  by  the  fact  that  in  face  presentation 
the  occiput  is  much  more  frequently  directed  to  the  right  than  to  the 
left ;  while  right  lateral  obliquity  of  the  uterus  is  also  much  more 
common. 

These  theories  assume  that  face  presentations  are  produced  during 
labor.  In  a  few  cases  they  certainly  exist  before  labor  has  commenced. 
It  is  possible,  however,  as  we  know  that  uterine  contractions  exist  in- 
dependently of  actual  labor,  that  similar  causes  may  also  be  in  opera- 
tion, although  less  distinctly,  before  the  commencement  of  labor. 

The  diagnosis  is  often  a  matter  of  considerable  difficulty  at  an 
early  period  of  labor,  before  the  os  is  fully  dilated  and  the  membranes 
ruptured,  and  when  the  face  has  not  entered  the  pelvic  cavity.  The 
finger  then  impinges  on  the  rounded  mass  of  the  forehead,  which  may 
very  readily  be  mistaken  for  the  vertex.  At  this  stage  the  diagnosis 
may  be  facilitated  by  abdominal  palpation  in  the  way  suggested  by 
Hecker.  If  the  face  is  presenting  at  the  brim,  palpation  will  enable 
us  to  distinguish  a  hard,  firm,  and  rounded  body,  immediately  above 
the  pubes,  which  is  the  forehead  and  sinciput ;  on  the  other  side  will 
be  felt  an  indistinct,  soft  substance,  corresponding  to  the  thorax  and 
neck.  When  labor  is  advanced,  and  the  head  has  somewhat  descended, 
or  when  the  membranes  are  ruptured,  Ave  should  be  able  to  make  out 
the  nature  of  the  presentation  with  certainty.  The  diagnostic  marks 
to  be  relied  on  are  the  edges  of  the  orbits,  the  prominence  of  the  nose, 
the  nostrils  (their  orifices  showing  to  which  part  of  the  pelvis  the  chin 
is  turned),  and  the  cavity  of  the  mouth,  with  the  alveolar  ridges.  If 
these  be  made  out  satisfactorily,  no  mistake  should  occur.  The  most 
difficult  cases  are  those  in  which  the  face  has  been  a  considerable  time 
in  the  pelvis.  Under  such  circumstances  the  cheeks  become  greatly 
swollen  and  pressed  together,  so  as  to  resemble  the  nates.  The  nose 
might  then  be  mistaken  for  the  genital  organs,  and  the  mouth  for  the 
anus.  The  orbits,  however,  and  the  alveolar  ridges,  resemble  nothing 
in  the  breech,  and  should  be  sufficient  to  prevent  error. 

Considerable  care  should  be  taken  not  to  examine  too  frequently 
and  roughly,  otherwise  serious  injury  to  the  delicate  structures  of  the 
face  might  be  inflicted.  When  once  the  presentation  has  been  satis- 
factorily diagnosed,  examinations  should  be  made  as  seldom  as  possible, 
and  only  to  assure  ourselves  that  the  case  is  progressing  satisfactorily. 

Mechanism. — If  we  regard  face  presentations,  as  Ave  are  fully  justified 
in  doing,  as  being  generally  produced  by  the  extension  of  the  occiput 
in  what  were  originally  vertex  presentations,  we  can  readily  under- 
stand that  the  position  of  the  face  in  relation  to  the  pelvis  must  cor- 
respond to  that  of  the  vertex.  This  is,  in  fact,  what  is  found  to  be 
the  case,  the  forehead  occupying  the  position  in  which  the  occiput 
would  have  been  placed  had  extension  not  occurred. 

The  face,  then,  like  the  head,  may  be  placed  witli  its  long  diameter 
corresponding  to  almost  any  of  the  diameters  of  the  brim,  but  most 
generally  it  lies  either  in  the  transverse  diameter,  or  between  this  and 
the  oblique,  while,  as  it  descends  in  the  pelvis,  it  more  generally  occu- 
pies one  or  other  of  the  oblique  diameters.  It  is  common  in  obstetric 
works  to  describe  two  principal  varieties  of  face  presentation,  viz.,  the 


326  LABOR. 

right  and  left  men  to-iliac,  according  as  the  chin  is  turned  to  one  or 
other  side  of  the  pelvis.  It  is  better,  however,  to  classify  the  positions 
in  accordance  with  the  part  of  the  pelvis  to  which  the  chin  points. 
We  may,  therefore,  describe  four  positions  of  the  face,  each  being 
analogous  to  one  of  the  ordinary  vertex  presentations,  of  which  it  is 
the  transformation. 

The  Four  Positions  generally  met  with. — First  position  (mento- 
dextra  posterior,  M.D.P.).  The  chin  points  to  the  right  sacro-iliac 
synchoudrosis,  the  forehead  to  the  left  foramen  ovale,  and  the  long 
diameter  of  the  face  lies  in  the  right  oblique  diameter  of  the  pelvis. 
This  corresponds  to  the  first  position  of  the  vertex,  and,  as  in  that,  the 
back  of  the  child  lies  to  the  left  side  of  the  mother. 

Second  position  (mento-laeva  posterior,  M.L.P.).  The  chin  points  to 
the  left  sacro-iliac  synchondrosis,  the  forehead  to  the  right  foramen 
ovale,  and  the  long  diameter  of  the  face  lies  in  the  left  oblique 
diameter  of  the  pelvis.  This  is  the  conversion  of  the  second  vertex 
position. 

Third  position  (mento-lseva  anterior,  M.L.A.).  The  forehead  (Fig. 
116)  points  to  the  right  sacro-iliac  synchondrosis,  the  chin  to  the  left 

FIG.  116. 


Third  position  (M.L.A.)  in  face  presentations. 

foramen  ovale,  and  the  long  diameter  of  the  face  lies  in  the  right 
oblique  diameter  of  the  pelvis.  This  is  the  conversion  of  the  third 
vertex  position. 

Fourth  position  (mento-dextra  anterior,  M.D.A.).  The  forehead  points 
to  the  left  sacro-iliac  synchondrosis,  the  chin  to  the  right  foramen 
ovale,  and  the  long  diameter  of  the  face  lies  in  the  left  oblique 
diameter  of  the  pelvis.  This  is  the  conversion  of  the  fourth  vertex 
position. 


PRESENTATIONS    OF    THE    FACE.  327 

The  relative  frequency  of  these  presentations  is  not  yet  positively 
ascertained.  It  is  certain  that  there  is  not  the  preponderance  of  first 
facial  (M.D.P.)  that  there  is  of  first  vertex  (O.L.A.)  positions,  and  this 
may,  no  doubt,  be  explained  by  the  supposition  that  an  unusual  vertex 
position  may  of  itself  facilitate  the  transformation  into  a  face  pres- 
entation. Winckel  concludes  that,  cceteris  paribus,  a  face  presentation 
is  more  readily  produced  when  the  back  of  the  child  lies  to  the  right 
than  when  it  lies  to  the  left  side  of  the  mother ;  the  reason  for  this 
being  probably  the  frequency  of  right  lateral  obliquity  of  the  uterus. 
We  shall  presently  see  that,  with  very  rare  exceptions,  it  is  absolutely 
essential  that  the  chin  should  rotate  forward  under  the  pubes  before 
delivery  can  be  accomplished  ;  and,  therefore,  we  may  regard  the  third 
and  fourth  face  positions,  in  which  the  chin  from  the  first  points  ante- 
riorly, as  more  favorable  than  the  first  and  second. 

The  mechanism  of  delivery  in  face  is  practically  the  same  as  in 
vertex  presentations;  and  we  shall  have  no  difficulty  in  understand- 
ing it  if  we  bear  in  mind  that  in  face  cases  the  forehead  takes  the 
place  of,  and  represents  the  occiput  in,  vertex  presentations.  For  the 
purpose  of  description  we  will  take  the  first  position  of  the  face. 

1.  Extension. — The  first  step  consists  in  the  extension  of  the  head, 
which  is  effected  by  the  uterine  contractions  as  soon  as  the  membranes 
are  ruptured.     By  this  the  occiput  is  still  more  completely  pressed 
back  on  the  nape  of  the  neck,  and  the  fron  to -mental,  rather  than  the 
mento-bregmatic,  diameter  is  placed  in  relation  to  the  pelvic  brim. 
This  corresponds  to  the  stage  of  flexion  in  vertex  presentations. 

The  chin  descends  below  the  forehead,  .from  precisely  the  same 
cause  as  the  occiput  in  vertex  presentations.  On  account  of  the  ex- 
tended position  of  the  head  the  presenting  face  is  divided  into  portions  of 
unequal  length  in  relation  to  the  vertebral  column,  through  which  the 
force  is  applied,  the  longer  lever  arm  being  toward  the  forehead.  The 
resistance  is,  therefore,  greatest  toward  the  forehead,  which  remains 
behind  while  the  chin  descends. 

2.  Descent. — As  the  pains  continue,  the  head  (the  chin  being  still 
in  advance)  is  propelled  through  the  pelvis.     It  is  generally  said  that 
the  face  cannot  descend,  like  the  occiput,  down  to  the  floor  of  the 
pelvis,  its  descent  being  limited  by  the  length  of  the  neck.     There  is 
here,  however,  an  obvious  misapprehension.     The  neck,  from  the  chin 
to  the  sternum,  when  the  head  is  forcibly  extended^  measures  from 
three  and  a  half  to  four  inches,  a  length  that  is  more  tnan  sufficient  to 
admit  of  the  face  descending  to  the  lower  pelvic  strait.     As  a  matter 
of  fact,  the  chin  is  frequently  observed  in  mento-posterior  positions  to 
descend  so  far  that  it  is  apparently  endeavoring  to  pass  the  perineum 
before  rotation  occurs.     At  the  brim  the  two  sides  of  the  face  are  on  a 
level,  but  as  labor  advances  the  right  cheek  descends  somewhat,  the 
<-aput  succedaneum  forms  on  the  malar  bone,  and,  if  a  secondary  caput 
succedaneum  form,  on  the  cheek. 

3.  Rotation  is  by  far  the  most  important  point  in  the  mechanism 
of  face  presentations ;  for  unless  it  occurs,  delivery,  with  a  full-sized 
head  and  an  average  pelvis,  is  practically  impossible.     There  are,  no 
doubt,  exceptions  to  this  rule,  which  must  be  separately  considered, 


328  LABOR. 

but  it  is  certain  that  the  absence  of  rotation  is  always  a  grave  and  for- 
midable complication  of  face  presentation.  Fortunately  it  is  only 
very  rarely  that  this  is  not  effected.  The  mechanical  causes  are  pre- 
cisely those  which  produce  rotation  of  the  occiput  forward  in  vertex 

FIG.  117. 


Rotation  forward  of  chin. 


presentations.  As  it  is  accomplished,  the  chin  passes  under  the  arch 
of  the  pubes,  and  the  occiput  rotates  into  the  hollow  of  the  sacrum 
(Fig.  117);  and  then  commences — 

4.  Flexion,  a  movement  which  corresponds  to  extension  in  vertex 
cases.    The  chin  passes  as  far  as  it  can  under  the  pubic  arch,  and  there 
becomes  fixed.     The  uterine  force  is  now  expended  on  the  occiput, 
which  revolves,  as  it  were,  on  its  transverse  axis  (Fig.  118),  the  under 
surface  of  the  chin  resting  on  the  pubes  as  a  fixed  point.     This  move- 
ment goes   on  until,  at  last,  the  face  and  occiput   sweep  over  the 
distended  perineum. 

5.  External  rotation  is  precisely  similar  to  that  which  takes  place 
in  head  presentations,  and,  like  it,  depends  on  the  movements  imparted 
to  the  shoulders. 

Such  is  the  natural  course  of  delivery  in  the  vast  majority  of  cases; 
but,  in  order  fully  to  understand  the  subject,  it  is  necessary  to  study 
those  rare  cases  in  which  the  chin  points  backward,  and  forward  rota- 
tion does  not  occur.  These  may  be  taken  to  correspond  to  the 
occipito-posterior  positions,  in  which  the  face  is  born  looking  to  the 
pubes ;  but,  unlike  them,  it  is  only  very  exceptionally  that  delivery 
can  be  naturally  completed.  The 'reason  of  this  is  obvious,  for  the 
occiput  gets  jammed  behind  the  pubes,  and  there  is  no  space  for  the 
fronto-mental  diameter  to  pass  the  antero-posterior  diameter  of  the  out- 
let (Fig.  119).  Cases  are  indeed  recorded  in  which  delivery  has  been 


PRESENTATIONS    OF    THE    FACE. 


329 


effected  with  the  chin  looking  posteriorly  ;  but  there  is  every  reason 
to  believe  that  this  can  only  happen  when  the  head  is  either  unusually 
small,  or  the  pelvis  unusually  large.  In  such  cases  the  forehead  is 


FIG.  118. 


Passage  of  the  head  through  the  external  parts  in  face  presentation. 

pressed  down  until  a  portion  appears  at  the  ostium  vaginae,  when  it 
becomes  firmly  fixed  behind  the  pubes,  and  the  chin,  after  many 


FIG.  119. 


Illustrating  the  position  of  the  head  when  forward  rotation  of  the  chin  does  not  take  place. 

efforts,  slips  over  the  perineum.  When  this  is  effected,  flexion  occurs, 
and  the  occiput  is  expelled  without  difficulty.  The  forehead  is 
probably  always  on  a  lower  level  than  the  chin. 


330  LABOR. 

Dr.  Hicks1  has  published  a  paper  in  which  he  attempts  to  show 
that  this  termination  of  face  presentations  is  not  so  rare  as  is  generally 
supposed,  and  he  gives  a  single  instance  in  which  he  effected  delivery 
with  the  forceps ;  but  he  practically  admits  that  special  conditions  are 
necessary,  such  as  the  "  antero-posterior  diameter  of  the  outlet  particu- 
larly ample,"  and  a  diminished  size  of  the  head.  When  delivery  is 
effected  it  is  probable,  as  Cazeaux  has  pointed  out,  that  the  face  lies  in 
the  oblique  diameter  of  the  outlet,  and  that  the  chin  depresses  the  soft 
structures  at  the  side  of  the  sacro-ischiatic  notch,  which  yield  to  the 
extent  of  a  quarter  of  an  inch  or  more,  and  thereby  permit  the  passage 
of  the  occipito-mental  diameter  of  the  head.  It  must,  however,  be 
borne  well  in  mind,  that  spontaneous  delivery  in  mento-posterior 
positions  is  the  rare  exception,  and  that,  supposing  rotation  does  not 
occur — and  it  often  does  so  at  the  last  moment — artificial  aid  in  one 
form  or  another  will  be  almost  certainly  required. 

Prognosis  of  Pace  Presentations. — As  regards  the  mother,  in  the 
great  majority  of  cases  the  prognosis  is  favorable,  but  the  labor  is  apt 
to  be  prolonged,  and  she  is,  therefore,  more  exposed  to  the  risks 
attending  tedious  delivery.  As  regards  the  child,  the  prognosis  is 
much  more  unfavorable  than  in  vertex  presentations.  Even  when  the 
anterior  rotation  of  the  chin  takes  place  in  the  natural  way,  it  is 
estimated  that  one  out  of  ten  children  is  stillborn ;  while,  if  not,  the 
death  of  the  child  is  almost  certain.  This  increased  infantile  mortality 
is  evidently  due  to  the  serious  amount  of  pressure  to  which  the  child 
is  subjected,  and  probably  depends  in  many  cases  on  cerebral  conges- 
tion, produced  by  pressure  on  the  jugular  veins,  as  the  neck  lies  in  the 
pelvic  cavity.  Even  when  the  child  is  born  alive,  the  face  is  always 
greatly  swollen  and  disfigured.  In  some  cases  the  deformity  produced 
in  this  way  is  excessive,  and  the  features  are  often  scarcely  recog- 
nizable. This  disfiguration  passes  away  in  a  few  days ;  but  the  prac- 
titioner should  be  aware  of  the  probability  of  its  occurrence,  and 
should  warn  the  friends,  or  they  might  be  unnecessarily  alarmed,  and 
possibly  might  lay  the  blame  on  him. 

Treatment. — After  what  has  been  said  as  to  the  mechanism  of 
delivery  in  face  presentation,  it  is  obvious  that  the  proper  course  is  to 
leave  the  case  alone,  in  the  expectation  of  the  natural  efforts  being 
sufficient  for  complete  delivery.  Fortunately,  in  the  large  majority  of 
cases,  this  course  is  attended  by  a  successful  result. 

The  old  accoucheurs,  as  has  been  stated,  thought  active  interference 
absolutely  essential,  and  recommended  either  podalic  version,  or  the 
attempt  to  convert  the  case  into  a  vertex  presentation,  by  inserting  the 
hand  and  bringing  down  the  occiput.  The  latter  plan  was  recom- 
mended by  Baudelocque,  and  is  even  yet  followed  by  some  accoucheurs. 
Thus  Dr.  Hodge2  advises  it  in  all  cases  in  which  face  presentation  is 
detected  at  the  brim  ;  but  although  it  might  not  have  been  attended 
with  evil  consequences  in  his  experienced  hands,  it  is  certainly  alto- 
gether unnecessary,  and  would  infallibly  lead  to  most  serious  results  if 
generally  adopted.  It  may,  however,  be  allowable  in  certain  cases  in 

1  Obstet.  Trans.,  1866,  vol.  vii.  p.  57.  2  System  of  Obstetrics,  p.  335. 


PRESENTATIONS    OF    THE    FACE.  331 

which  the  face  remains  above  the  brim,  and  refuses  to  descend  into  the 
pelvic  cavity.  Even  then  it  is  questionable  whether  podalic  version 
should  not  be  preferred,  as  being  easier  of  performance,  giving,  when 
once  effected,  a  much  more  complete  control  over  delivery,  and  being 
less  painful  to  the  mother.  Version  is  certainly  preferable  to  the 
application  of  the  forceps,  which  are  introduced  with  difficulty  in  so 
high  a  position  of  the  lace,  and  do  not  take  a  secure  hold,  provided 
the  face  has  not  emerged  from  the  mouth  of  the  uterus.  If  it  has 
passed  through  the  cervix,  version  could  not  be  effected  without  serious 
risk  of  rupture  of  the  uterus. 

Schatz1  has  more  recently  suggested  the  rectification  efface  presenta- 
tions at  an  early  stage,  before  the  rupture  of  the  membranes,  by  manip- 
ulation through  the  abdomen.  He  raises  the  foetal  body  by  pressure 
on  the  shoulder  and  breast  through  the  abdominal  wall  by  one  hand, 
while  the  breech  is  raised  and  steadied  by  the  other.  By  this  means 
the  occiput  is  elevated,  and  then  the  breech  is  pressed  downward,  when 
head  flexion  is  produced  by  the  resistance  of  the  pelvic  walls.  Of  this 
method  I  have  had  no  practical  experience,  but  it  obviously  requires 
an  unusual  amount  of  skill  and  practice  in  abdominal  palpation. 

When  once  the  face  has  descended  into  the  pelvis,  difficulties  may 
arise  from  two  chief  causes  :  uterine  inertia,  and  non-rotation  forward 
of  the  chin. 

The  treatment  of  the  former  class  must  be  based  on  precisely  the 
same  general  principles  as  in  dealing  with  protracted  labor  in  vertex 
presentations.  The  forceps  may  be  applied  with  advantage,  bearing 
in  mind  the  necessity  of  getting  the  chin  under  the  pubes,  and,  when 
this  has  been  effected,  of  directing  the  traction  forward,  so  as  to  make 
the  occiput  slowly  and  gradually  distend  and  sweep  over  the  perineum. 

The  "second  class  of  difficult  face  cases  is  much  more  important, 
and  may  try  the  resources  of  the  accoucheur  to  the  utmost.  Our  first 
endeavor  must  be,  if  possible,  to  secure  the  anterior  rotation  of  the 
chin.  For  this  purpose  various  manoeuvres  are  recommended.  By 
some,  we  are  advised  to  introduce  the  finger  cautiously  into  the  mouth 
of  the  child,  and  draw  the  chin  forward  during  a  pain  ;  by  others,  to 
pass  the  finger  up  behind  the  occiput  and  press  it  backward  during  the 
pain.  Schroeder  points  out  that  the  difficulty  often  depends  on  the 
fact  of  the  head  not  being  sufficiently  extended,  so  that  the  chin  is  not 
on  a  lower  level  than  the  forehead ;  and  that  rotation  is  best  promoted 
by  pressing  the  forehead  upward  with  the  finger  during  a  pain,  so  as 
to  cause  the  chin  to  descend.  Penrose2  believes  that  non-rotation  is 
generally  caused  by  the  want  of  a  point  d'appui  below,  on  account  of 
the  face  being  unable  to  descend  to  the  floor  of  the  pelvis,  and  that,  if 
this  is  supplied,  rotation  will  take  place.  In  such  cases  he  applies  the 
hand,  or  the  blade  of  the  forceps,  so  as  to  press  on  the  posterior  cheek. 
By  this  means  the  necessary  point  d'appui  is  given  ;  and  he  relates 
several  interesting  cases  in  which  this  simple  manoeuvre  was  effectual 
in  rapidly  terminating  a  previously  lengthy  labor.  Any,  or  all,  of 
these  plans  may  be  tried.  We  must  bear  in  mind,  in  using  them,  that 

1  Arch.  f.  Gyn.,  1S73,  Bd.  v.  S.  313. 

*  Amer.  Supplement  to  Obst.  Journ.,  1876-77,  vol.  iv.  p.  1 . 


832 


LABOR. 


rotation  is  often  delayed  until  the  face  is  quite  at  the  lower  pelvic 
strait,  so  that  we  need  not  too  soon  despair  of  its  occurring.  If,  how- 
ever, in  spite  of  these  manoeuvres,  it  does  not  take  place,  what  is  to  be 
done?  If  the  head  has  not  passed  through  the  mouth  of  the  uterus, 
turning  would  be  the  simplest  and  most  effectual  plan.  I  have  suc- 
ceeded in  delivering  in  this  way,  when  all  attempts  at  producing  rota- 
tion had  failed ;  but  generally  the  face  will  be  too  decidedly  engaged 
to  render  it  possible.  An  attempt  might  be  made  to  bring  down  the 
occiput  by  the  vectis,  or  by  a  fillet ;  but  if  the  face  be  in  the  pelvic 
cavity,  it  is  hardly  possible  for  this  plan  to  succeed.  An  endeavor 
may  be  made  to  produce  rotation  by  the  forceps ;  but  it  should  be 
remembered  that  rotation  of  the  face  mechanically  iu  this  way  is  very 
difficult,  and  much  more  likely  to  be  attended  with  fatal  consequences 
to  the  child  than  when  it  is  effected  by  the  natural  efforts.  In  using 
forceps  for  this  purpose,  the  second  or  pelvic  curve  is  likely  to  prove 
injurious,  and  a  short  straight  instrument  is  to  be  preferred.  If  rota- 
tion be  found  to  be  impossible,  an  endeavor  may  be  made  to  draw  the 
face  downward,  so  as  to  get  the  chin  over  the  perineum,  and  deliver 
in  the  mento-posterior  position  ;  but  unless  the  child  be  small,  or  the 
pelvis  very  capacious,  the  attempt  is  unlikely  to  succeed.  Finally,  if 
all  these  means  fail,  there  is  no  resource  left  but  lessening  the  size  of 
the  head  by  craniotomy,  a  dernier  ressort  which,  fortunately,  is  very 
rarely  required,  but  which  is  certainly  preferable  to  long-continued 
and  violent  endeavors  to  deliver  with  the  chin  pointing  backward. 

Brow  Presentations. — It  sometimes  happens  that  the  head  is  par- 
tially extended,  so  as  to  bring  the  os  fronds  into  the  brim  of  the  pelvis, 
and  form  what  is  described  as  a  brow  presentation.  Should  the  head 
descend  in  this  manner,  the  difficulties,  although  not  insuperable,  are 
apt  to  be  very  great,  from  the  fact  that  the  long  cervico-frontal  diam- 
eter of  the  head  is  engaged  in  the  pelvic  cavity.  The  diagnosis  is  not 

difficult,  for  the  os  frontis  wrill  be  detected 
by  its  rounded  surface,  while  the  anterior 
fontanelle  is  within  reach  in  one  direc- 
tion, the  orbit  and  root  of  the  nose  in 
another. 

Fortunately,  in  the  large  majority  of 
cases,  brow  presentations  are  spontane- 
ously converted  into  either  vertex  or  face 
presentations,  according  as  flexion  or  ex- 
tension of  the  head  occurs ;  and  these 
must  be  regarded  as  the  desirable  termi- 
nations and  the  ones  to  be  favored.  For 
this  purpose  upward  pressure  must  be 
made  on  one  or  other  extremity  of  the 
presenting  part  during  a  pain,  so  as  to 
favor  flexion  or  extension ;  or,  if  the 
parts  be  sufficiently  dilated,  an  attempt 
may  be  made  to  pass  the  hand  over  the  occiput  and  draw  it  down,  thus 
performing  cephalic  version.  The  latter  is  the  plan  recommended  by 
Hodge,  who  describes  the  operation  as  easy.  Long,  in  an  excellent 


FIG.  120. 


Brow  presentation,  subsequently 
converted  into  that  of  the  face. 
(After  LUSK.) 


DIFFICULT    OCCIPITO-POSTERIOR    POSITIONS.  333 

paper  on  this  subject,  has  given  figures  to  show  that  correction  of  the 
malpresentation  by  manipulation  has  given  better  results  than  any 
other  method  of  treatment.1  It  is  questionable,  however,  if  a  well- 
marked  brow  presentation  be  distinctly  made  out  while  the  head  is 
still  at  the  brim,  whether  podalic  version  would  not  be  the  easiest  and 
best  operation.  If  the  forehead  has  descended  too  low  for  this,  and 
if  the  endeavor  to  convert  it  into  either  a  face  or  vertex  presentation 
fails,  the  forceps  will  probably  be  required.  In  such  cases  the  face 
generally  turns  toward  the  pubes,  the  superior  maxilla  becomes  fixed 
behind  the  pubic  arch,  and  the  occiput  sweeps  over  the  perineum. 
Very  great  difficulty  is  likely  to  be  experienced,  and,  if  conversion 
into  either  a  vertex  or  face  presentation  cannot  be  effected,  craniotomy 
is  not  unlikely  to  be  required.  After  birth  the  head  will  "be  unusually 
disfigured  from  the  pressure  to  which  it  has  been  subjected,  the  swell- 
ing mainly  forming  over  the  forehead,  between  the  root  of  the  nose 
and  the  anterior  angle  of  the  greater  fontanelle  (Fig.  120). 


CHAPTER    VII. 

DIFFICULT  OCCIPITO-POSTERIOR   POSITIONS. 

A  FEW  words  may  be  said  in  this  place  as  to  the  management  of 
occipito-posterior  positions  of  the  head,  especially  of  those  in  which 
forward  rotation  of  the  occiput  does  not  take  place.  It  has  already 
been  pointed  out  that,  in  the  large  majority  of  these  cases,  the  occiput 
rotates  forward  without  any  particular  difficulty,  and  the  labor  termi- 
nates in  the  usual  way  with  the  occiput  emerging  under  the  arch  of 
the  pubes. 

In  a  certain  number  of  cases  such  rotation  does  not  occur,  and  diffi- 
culty and  delay  are  apt  to  follow.  The  proportion  of  cases  in  which 
face-to-pubes  terminations  of  occipito-posterior  positions  occur  has 
been  variously  estimated,  and  they  are  certainly  more  common  than 
most  of  our  text-books  lead  us  to  expect.  Dr.  Uvedale  West,1  who 
studied  the  subject  with  great  care,  found  that  labor  ended  in  this 
way  in  79  out  of  2585  births,  all  these  deliveries  being  exceptionally 
difficult. 

Causes  of  Face-to-Pubes  Delivery. — He  believed  that  forward 
rotation  of  the  head  is  prevented  by  the  absence  of  flexion  of  the  chin 
on  the  sternum,  so  that  the  long  occipito-frontal  (O.F.),  instead  of  the 
short  sub-occipito-bregmatic  (S.O.B.),  diameter  of  the  head  is  brought 
into  contact  with  the  pelvic  diameter ;  hence  the  occiput  is  no  longer 
the  lowest  point,  and  is  not  subjected  to  the  action  of  those  causes 

i  American  Journal  of  Obstetrics,  1885,  vol.  xviii.  p.  897. 
a  Cranial  Presentations,  p.  33. 


334  LABOR. 

which  produce  forward  rotation.  Dr.  Macdonald,  who  has  written  a 
thoughtful  paper  on  the  subject,1  believes  that  the  non-rotation  forward 
of  the  occiput  is  chiefly  due  to  the  large  size  of  the  head,  in  conse- 
quence of  which  "the  forehead  gets  so  wedged  into  the  pelvis  anteriorly 
that  its  tendency  to  slacken  and  rotate  backward  does  not  come  into 
play."  Dr.  West's  explanation,  which  has  an  important  bearing  on 
the  management  of  these  cases,  seems  to  explain  most  correctly  the 
non-occurrence  of  the  natural  rotation. 

The  important  question  for  us  to  decide  is,  How  can  we  best  assist 
in  the  management  of  cases  of  this  kind  when  difficulties  arise,  and 
labor  is  seriously  retarded  ? 

Mode  of  Treatment  of  Such  Cases. — Dr.  West,  insisting  strongly 
on  the  necessity  of  complete  flexion  of  the  chin  on  the  sternum,  advises 
that  this  should  be  favored  by  upward  pressure  on  the  frontal  bone, 
with  the  view  of  causing  the  chin  to  approach  the  sternum,  and  the 
occiput  to  descend,  and  thus  to  come  within  the  action  of  the  agencies 
which  favor  rotation.  Supposing  the  pains  to  be  strong,  and  the 
fontanclle  to  be  readily  within  reach,  we  may,  in  this  way,  very  pos- 
sibly favor  the  descent  of  the  occiput,  and  without  injuring  the 
mother,  or  increasing  the  difficulties  of  the  case  in  the  event  of  the 
manoeuvre  failing.  The  beneficial  effects  of  this  simple  expedient  are 
sometimes  very  remarkable.  In  two  cases  in  which  I  recently  adopted 
it,  labor,  previously  delayed  for  a  length  of  time  without  any  apparent 
progress,  although  the  pains  were  strong  and  effective,  was  in  each 
instance  rapidly  finished  almost  immediately  after  the  upward  press- 
ure was  applied.  The  rotation  of  the  face  backward  may  at  the  same 
time  be  favored  by  pressure  on  the  pubic  side  of  the  forehead  during 
the  pains. 

Others  have  advised  that  the  descent  of  the  occiput  should  be  pro- 
moted by  downward  traction,  applied  by  the  vectis  or  fillet.  The 
latter  is  the  plan  specially  advocated  by  Hodge ; 2  and  the  fillet  cer- 
tainly finds  one  of  its  most  useful  applications  in  cases  of  this  kind, 
as  being  simpler  of  application  and  probably  more  effective  than  the 
vectis. 

Although  any  of  these  methods  may  be  adopted,  a  word  of  caution 
is  necessary  against  prolonged  and  over-active  endeavors  at  producing 
flexion  and  rotation  when  that  seems  delayed.  All  who  have  watched 
such  cases  must  have  observed  that  rotation  often  occurs  spontaneously 
at  a  very  advanced  period  of  labor,  long  after  the  head  has  been 
pressed  down  for  a  considerable  time  to  the  very  outlet  of  the  pelvis, 
and  when  it  seems  to  have  been  making  fruitless  endeavors  to  emerge  ; 
so  that  a  little  patience  will  often  be  sufficient  to  overcome  the  diffi- 
culty. 

Bataillard3  advises  the  introduction  of  the  antisepticized  hand  when 
rotation  does  not  occur,  with  which  the  head  is  dislodged  from  the 
sacrum,  and  gently  rotated  forward.  He  relates  many  instances  in 
which  this  manoeuvre  was  successful.  Should  it  fail,  and  farther 

1  Edin.  Med.  Journ.,  1874-75,  vol.  xx.  p.  302. 

2  System  of  Obstetrics,  p.  308. 
8  Ann.  deGyn.,  August,  1889. 


DIFFICULT    OCCIPITO-POSTERIOR    POSITIONS.  335 

assistance  be  required,  there  is  no  reason  why  the  forceps  should  not 
be  used.  The  instrument  is  not  more  difficult  to  apply  than  under 
ordinary  circumstances,  nor,  as  a  rule,  is  much  more  traction  necessary. 
Dr.  Macdonald,  indeed,  in  the  paper  already  alluded  to,  maintains  that 
in  persistent  occipito-posterior  positions  there  is  almost  always  a  want 
of  proportion  between  the  head  and  the  pelvis,  and  that,  therefore,  the 
forceps  will  be  generally  required,  and  he  prefers  them  to  any  artificial 
attempts  at  rectification.  Some  peculiarities  in  the  mode  of  delivery 
are  necessary  to  bear  in  mind.  In  most  works  it  is  taught  that  the 
operator  should  pay  special  attention  to  the  rotation  of  the  head,  and 
should  endeavor  to  impart  this  movement  by  turning  the  occiput  for- 
ward during  extraction.  Thus  Tyler  Smith  says  :  "  In  delivery  with 
the  forceps  in  occipito-posterior  presentations,  the  head  should  be 
slowly  rotated  during  the  process  of  extraction  so  as  to  bring  the 
vertex  toward  the  pubic  arch,  and  thus  convert  them  into  occipito- 
auterior  presentations."  The  danger  accompanying  any  forcible 
attempt  at  artificial  rotation  will,  however,  be  evident  on  slight  con- 
sideration. It  is  true  that  in  many  cases,  when  simple  traction  is 
applied,  the  occiput  will,  of  itself,  rotate  forward,  carrying  the  instru- 
ment with  it.  But  that  is  a  very  diiferent  thing  from  forcibly  twisting 
the  head  around  with  the  blades  of  the  forceps,  without  any  assurance 
that  the  body  of  the  child  will  follow  the  movement.  It  is  impossible 
to  conceive  that  such  violent  interference  would  not  be  attended  with 
serious  risk  of  injury  to  the  neck  of  the  child.  If  rotation  do  not 
occur,  the  fair  inference  is  that  the  head  is  so  placed  as  to  render 
delivery  with  the  face  to  the  pubes  the  best  termination,  and  no 
endeavor  should  be  made  to  prevent  it.  This  rule  of  leaving  the 
rotation  entirely  to  Nature,  and  using  traction  only,  has  received  the 
approval  of  Barnes  and  most  modern  authorities,  and  is  the  one  which 
recommends  itself  as  the  most  scientific  and  reasonable. 

There  are  cases  in  which  the  pelvic  curve  of  the  forceps  is  of 
doubtful  utility.  When  applied  in  the  usual  way  the  convexity  of 
the  blades  points  backward.  If  rotation  accompany  extraction,  the 
blades  necessarily  follow  the  movement  of  the  head,  and  their  convex 
edges  will  turn  forward.  It  certainly  seems  probable  that  such  a 
movement  would  subject  the  maternal  soft  parts  to  considerable  risk. 
I  have,  however,  more  than  once  seen  such  rotation  of  the  instrument 
happen  without  any  apparent  bad  result ;  but  the  dangers  are  obvious. 
Hence  it  would  be  a  wise  precaution,  either  to  use  a  pair  of  straight 
forceps  for  this  particular  operation,  or  to  remove  the  blades  and  leave 
the  case  to  be  terminated  by  the  natural  powers,  when  the  head  is  at 
the  lower  strait,  and  rotation  seems  about  to  occur.  Prof.  Richardson ' 
advises  that  when  forceps  are  applied  in  persistent  occipito-posterior 
positions,  they  should  be  introduced  with  the  pelvic  curve  reversed. 
He  claims  for  this  method  that  the  traction  is  chiefly  exerted  on  the 
occiput,  where  it  is  most  needed,  which  thereby  descends  and  produces 
the  necessary  flexion  of  the  chin  on  the  sternum.  The  forceps  are 
then  removed,  and,  if  the  pains  are  sufficient,  rotation  forward  is  sure 

1  Medical  Communications  of  the  Massachusetts  Medical  Society,  1885,  vol.  xiii.  No.  4. 


336  LABOR. 

to  take  place.  Of  this  plan  I  have  no  personal  experience.  When 
there  is  no  rotation,  more  than  usual  care  should  be  taken  with  the 
perineum,  which  is  necessarily  much  stretched  by  the  rounded  occiput. 
Indeed,  the  risk  to  the  perineum  is  very  considerable,  and,  even  with 
the  greatest  care,  it  may  be  impossible  to  avoid  laceration. 

Bearing  these  precautions  in  mind,  delivery  with  the  forceps  in 
occipito-posterior  positions  offers  no  special  difficulties  or  dangers. 

[Version  by  the  Vertex. — The  following  are  the  teachings  of 
several  eminent  American  obstetricians  upon  the  management  of 
occipito-posterior  positions : 

1 .  "In  primitive   oblique  occipito-posterior  positions  of  the  head 
Nature  will  almost  without  exception  cause  spontaneous  rotation  of 
the  occiput  to  the  symphysis  pubis ;  but  to  favor  this  movement  the 
bag  of  waters  should  be  preserved." 

2.  "  Spontaneous  rotation,  as  a  rule,  does  not  begin  until  the  head 
meets  with  resistance  from  the  floor  of  the  pelvis  :  hence  no  effort  to 
force  rotation  should  be  made  until  Nature  has  proved  herself  inade- 
quate." 

3.  "  Where  rotation  forward  is  prevented,  it  is  probably  due  to  the 
position  of  the  occiput  having  been  originally  directly  backward,  and 
only  becoming  oblique  after  the  descent  of  the  head  into  the  pelvis, 
the  position  of  the  child's  body  preventing  the  anterior  movement  of 
its  occiput ;  that  is,  the  sixth  position  of  Hodge  has  changed  into  a 
fourth    or   fifth,   but  .will  not  without  assistance    become  a  first  or 
second." 

4.  "  If,  then,  rotation  is  not  spontaneous  after  the  head  reaches  the 
floor  of  the  pelvis,  version  by  the  vertex  will  not  take  place,  except  it 
be  forced  by  the  vectis  or  forceps." 

Use  of  the  Hand  in  Occipito-posterior  Positions. — The  intro- 
duction of  the  hand  for  the  purpose  of  effecting  version  by  the  vertex 
was  strongly  advocated  by  the  late  Dr.  John  S.  Parry,  of  Philadelphia, 
whose  hand  was  very  small  and  thin,  and  could  be  used  to  great  ad- 
vantage. Prof.  Ottavio  Morisani,  of  Naples,  is  said  to  use  his  with 
even  greater  success,  because  of  its  smaller  size.  Large  hands  should 
not  be  used  in  primiparae.  By  this  manoeuvre  I  once  brought  an 
occiput  under  the  pubic  arch  of  a  primipara  in  three  pains,  after  she 
had  labored  for  hours  to  deliver  herself. — ED.] 


CHAPTER   VIII. 

PRESENTATIONS    OF    THE    SHOULDER,   ARM,   OR    TRUNK.— 
COMPLEX  PRESENTATIONS.— PROLAPSE  OF  THE  FUNIS. 

Ix  the  presentations  already  considered  the  long  diameter  of  the 
foetus  corresponded  with  that  of  the  uterine  cavity,  and  in  all  of  them 
the  birth  of  the  child  by  the  maternal  efforts  was  the  general  and 


PRESENTATIONS    OF    SHOULDER,    ETC.  337 

normal  termination  of  labor.  We  have  now  to  discuss  those  important 
cases  in  which  the  long  diameter  of  the  foetus  and  uterus  do  not  cor- 
respond, but  in  which  the  long  foetal  diameter  lies  obliquely  across  the 
uterine  cavity.  In  the  large  majority  of  these  it  is  either  the  shoulder 
or  some  part  of  the  upper  extremity  that  presents ;  for  it  is  an  admitted 
fact  that,  although  other  parts  of  the  body,  such  as  the  back  or  ab- 
domen, may,  in  exceptional  cases,  lie  over  the  os  at  an  early  period  of 
labor,  yet,  as  labor  progresses,  such  presentations  are  almost  always 
converted  into  those  of  the  upper  extremity. 

For  all  practical  purposes  we  may  confine  ourselves  to  a  considera- 
tion of  shoulder  presentations;  the  further  subdivision  of  these  into 
elbow  or  hand  presentations  being  no  more  necessary  than  the  division 
of  pelvic  presentations  into  breech,  knee,  and  footling  cases,  since  the 
mechanism  and  management  are  identical,  whatever  part  of  the  upper 
extremity  presents. 

There  is  this  great  distinction  between  the  presentations  we  are  now 
considering  and  those  already  treated  of,  that,  on  account  of  the  rela- 
tions of  the  foetus  to  the  pelvis,  delivery  by  the  natural  powers  is 
impossible,  except  under  special  and  very  unusual  circumstances  that 
can  never  be  relied  upon.  Intervention  on  the  part  of  the  accoucheur 
is,  therefore,  absolutely  essential,  and  the  safety  of  both  the  mother 
and  child  depends  upon  the  early  detection  of  the  abnormal  position 
of  the  foetus;  for  the  necessary  treatment,  which  is  comparatively  easy 
and  safe  before  labor  has  been  long  in  progress,  becomes  most  difficult 
and  hazardous  if  there  have  been  much  delay. 

FIG.  121. 


Dorso-anterior  presentation  of  the  arm  (S.L.A.). 


Position  of  the  Foetus. — Presentations  of  the  upper  extremity  or 
trunk  are  often  spoken  of  as  transverse  presentations  or  cross-births ; 
but  both  of  these  terms  are  misleading,  as  they  imply  that  the  foetus 
is  placed  transversely  in  the  uterine  cavity,  or  that  it  lies  directly 
across  the  pelvic  brini.  As  a  matter  of  fact,  this  is  never  the  case,  for 

22 


338 


LABOR. 


the  child  lies  obliquely  in  the  uterus,  not  indeed  in  its  long  axis,  but 
in  one  intermediate  between  its  long  and  transverse  diameters. 

Two  great  divisions  of  shoulder  presentations  are  recognized :  the 
one  in  which  the  back  of  the  child  looks  to  the  abdomen  of  the  mother 
(Fig.  121),  and  the  other  in  which  the  back  of  the  child  is  turned 
toward  the  spine  of  the  mother  (Fig.  122).  Each  of  these  is  sub- 

FIG.  122. 


Dorso-posterior  presentation  of  the  arm  (S.D.P.), 

divided  into  two  subsidiary  classes,  according  as  the  head  of  the  child 
is  placed  in  the  right  or  left  iliac  fossa.  Thus  in  dorso-anterior  posi- 
tions, if  the  head  lie  in  the  left  iliac  fossa  (left  scapula  anterior — scapula- 
laeva  anterior,  S.L.A.),  the  right  shoulder  of  the  child  presents ;  if  in 
the  right  iliac  fossa  (right  scapula  anterior — scapula-dextra  anterior, 
S.D.A.),  the  left.  So  in  dorso-posterior  positions,  if  the  head  lie  in  the 
left  iliac  fossa  (left  scapula  posterior — scapula-lseva  posterior,  S.L.P.),  the 
left  shoulder  presents ;  if  in  the  right,  the  right  (right  scapula  posterior — 
scapula-dextra  posterior,  s.D.p.).1  Of  the  two  classes  the  dorso-anterior 
positions  are  more  common — in  the  proportion,  it  is  said,  of  two  to  one. 
The  causes  of  shoulder  presentation  are  not  well  known.  Amongst 
those  most  commonly  mentioned  are  prematurity  of  the  foetus,  aud 
excess  of  liquor  amnii ;  either  of  these,  by  increasing  the  mobility  of 
the  foetus  in  utero,  would  probably  have  considerable  influence.  The 
fact  that  it  occurs  much  more  frequently  amongst  premature  births  has 
long  been  recognized.  Undue  obliquity  of  the  uterus  has  probably  some 
influence,  since  the  early  pains  might  cause  the  presenting  part  to 
hitch  against  the  pelvic  brim,  and  the  shoulders  to  descend.  An  un- 
usually low  attachment  of  the  placenta  to  the  inferior  segment  of  the 

1  Left  and  right  refer  in  this  nomenclature,  as  in  all  positions,  to  the  left  and  right  side  of  the 
mother  without  regard  to  that  of  the  child. 


PRESENTATIONS    OF    SHOULDER,    ETC.  339 

uterine  cavity  has  been  mentioned  as  a  predisposing  cause.  In  conse- 
quence of  this  the  head  does  not  lie  so  readily  in  the  lower  uterine 
segment,  and  is  apt  to  slip  up  into  one  of  the  iliac  fossae.  This  is  sup- 
posed to  explain  the  frequency  of  arm  presentation  in  cases  of  partial 
or  complete  placenta  prsevia.  Dauyau  and  AVigand  believe  that 
shoulder  presentations  are  favored  by  irregularity  in  the  shape  of  the 
uterine  cavity,  especially  a  relative  increase  in  its  transverse  diameter. 
This  theory  has  been  generally  discredited  by  writers,  and  it  is  cer- 
tainly not  susceptible  of  proof;  but  it  seems  far  from  unlikely  that 
some  peculiarity  of  shape  may  exist,  not  capable  of  recognition,  but 
sufficient  to  influence  the  position  of  the  fretus.  How  otherwise  are 
we  to  explain  those  remarkable  cases,  many  of  which  are  recorded,  in 
which  similar  malpositions  occurred  in  many  successive  labors  ?  Thus 
Joulin  refers  to  a  patient  who  had  an  arm  presentation  in  three  suc- 
cessive pregnancies,  and  to  another  who  had  shoulder  presentation  in 
three  out  of  four  labors,  while  Eustache,  of  Lille,1  describes  the  case 
of  a  patient  who  had  thirteen  shoulder  presentations  out  of  fourteen 
deliveries.  Certainly,  such  constant  recurrences  of  the  same  abnor- 
mality could  only  be  explained  on  the  hypothesis  of  some  very  per- 
sistent cause  such  as  that  referred  to.  Pinard2  states  that  shoulder 
presentations  are  seven  times  more  common  in  multipart  than  in  pri- 
miparse,  in  consequence,  as  he  believes,  of  the  laxity  of  the  abdominal 
walls  in  the  former,  which  allows  the  uterus  to  fall  forward,  and  thus 
prevents  the  head  entering  the  pelvic  brim  in  the  latter  weeks  of  preg- 
nancy. It  is  probable  that  merely  accidental  causes  have  most  influ- 
ence in  the  production  of  shoulder  presentation,  such  as  falls,  or  undue 
pressure  exerted  on  the  abdomen  by  badly  fitting  or  tight  stays.  Par- 
tially transverse  positions  during  pregnancy  are  certainly  much  more 
common  than  is  generally  believed,  and  may  often  be  detected  by 
abdominal  palpation.  The  tendency  is  for  such  malpositions  to  be 
righted  either  before  labor  sets  in,  or  in  the  early  period  of  labor ;  but 
it  is  quite  easy  to  understand  how  any  persistent  pressure,  applied  in 
the  manner  indicated,  may  perpetuate  a  position  which  otherwise 
would  have  been  only  temporary. 

Prognosis  and  Frequency. — According  to  Churchill's  statistics, 
shoulder  presentations  occur  about  once  in  260  cases ;  that  is,  only 
slightly  less  frequently  than  those  of  the  face.  Spiegelberg  found  it 
1  in  180  ;  while  in  France  the  combined  statistics  of  several  accoucheurs 
show  a  frequency  of  1  in  117.  The  prognosis  to  both  the  mother  and 
child  is  much  more  unfavorable  ;  for  he  estimates  that  out  of  235  cases, 
1  in  9  of  the  mothers  and  half  the  children  were  lost.  The  prognosis 
in  each  individual  case  will,  of  course,  vary  much  with  the  period  of 
delivery  at  which  the  malposition  is  recognized.  If  detected  early, 
interference  is  easy,  and  the  prognosis  ought  to  be  good  ;  whereas  there 
are  few  obstetric  difficulties  more  trying  than  a  case  of  shoulder  pre- 
sentation, in  which  the  necessary  treatment  has  been  delayed  until  the 
presenting  part  has  been  tightly  jammed  into  the  cavity  of  the  pelvis. 

Diagnosis. — Bearing  this  fact  in  mind,  the  paramount  necessity  of 

i  Nouv.  Arch.  d'Obstet.  et  Gyn.,  1889. 

*  Annul.  d'Hyg.  pub.  et  de  Med.,  Jan.  1879. 


340  LABOR. 

an  accurate  diagnosis  will  be  apparent;  and  it  is  specially  important 
that  we  should  be  able  not  only  to  detect  that  a  shoulder  or  arm  is  pre- 
senting, but  that  we  should,  if  possible,  determine  which  it  is,  and  how 
the  body  and  head  of  the  child  are  placed.  The  existence  of  a  shoulder 
presentation  is  not  generally  suspected  until  the  first  vaginal  examina- 
tion is  made  during  labor.  The  practitioner  will  then  be  struck  with 
the  absence  of  the  rounded  mass  of  the  foetal  head,  and,  if  the  os  be 
opened  and  the  membranes  protruding,  by  their  elongated  form,  which 
is  common  to  this  and  to  other  malpresentations.  If  the  presenting 
part  be  too  high  to  reach,  as  is  often  the  case  at  an  early  period  of 
labor,  an  endeavor  should  at  once  be  made  to  ascertain  the  foetal  posi- 
tion by  abdominal  examination.  This  is  the  more  important  as  it  is 
much  more  easy  to  recognize  presentations  of  the  shoulder  in  this  way 
than  those  of  the  breech  or  foot ;  and,  at  so  early  a  period,  it  is  often 
not  only  possible  but  comparatively  easy,  to  alter  the  position  of  the 
foetus  by  abdominal  manipulation  alone  and  thus  avoid  the  necessity 
of  the  more  serious  form  of  version.  The  method  of  detecting  a 
shoulder  presentation  by  examination  of  the  abdomen  has  already  been 
described  (p.  129),  and  need  not  be  repeated.  The  chief  points  to  look 
for  are,  the  altered  shape  of  the  uterus,  and  two  solid  masses,  the  head 
and  the  breech,  one  in  either  iliac  fossa.  The  facility  with  which  these 
parts  may  be  recognized  varies  much  in  different  patients.  In  thin 
women,  with  lax  abdominal  parietes,  they  can  be  easily  felt,  while  in 
very  stout  women  it  may  be  impossible.  Failing  this  method,  we  must 
rely  on  vaginal  examinations ;  although,  before  the  membranes  are 
ruptured,  and  when  the  presenting  part  is  high  in  the  pelvis,  it  is  not 
always  easy  to  gain  accurate  information  in  this  way.  The  difficulty 
is  increased  by  the  paramount  importance  of  retaining  the  membranes 
intact  as  long  as  possible.  It  should  be  remembered,  therefore,  that 
when  a  presentation  of  the  superior  extremitv  is  suspected,  the  neces- 
sary examinations  should  only  be  made  in  the  intervals  between  the 
pains  when  the  membranes  are  lax,  and  never  when  they  are  rendered 
tense  by  the  uterine  contractions. 

As  either  the  shoulder,  the  elbow,  or  the  hand  may  present,  it  will 
be  best  to  describe  the  peculiarities  of  each  separately,  and  the  means 
of  distinguishing  to  which  side  of  the  body  the  presenting  part 
belongs. 

1.  The  shoulder  is  recognized  as  a  round  smooth  prominence,  at 
one  point  of  which  may  often  be  felt  the  sharp  edge  of  the  acromion. 
If  the  finger  can  be  passed  sufficiently  high,  it  may  be  possible  to  feel 
the  clavicle,  and  the  spine  of  the  scapula.  A  still  more  complete  ex- 
amination may  enable  us  to  detect  the  ribs  and  the  intercostal  spaces, 
which  would  be  quite  conclusive  as  to  the  nature  of  the  presentation, 
and  there  is  nothing  resembling  them  in  any  other  part  of  the  body. 
At  the  side  of  the  shoulder,  the  hollow  of  the  axilla  may  generally  be 
made  out. 

In  order  to  ascertain  the  position  of  the  child,  we  have  to  find  out 
in  which  iliac  fossa  the  head  lies.  This  may  be  done  in  two  ways  : 
1st,  the  head  may  be  felt  through  the  abdominal  parietes  by  palpation  ;' 
and  2d,  since  the  axilla  always  points  toward  the  feet,  if  it  point  to 


PRESENTATIONS    OF    SHOULDER,    ETC.  341 

the  left  side  the  head  must  lie  in  the  right  iliac  fossa;  if  to  the  right, 
the  head  must  be  placed  in  the  left  iliac  fossa.  Again,  the  spine  of  the 
scapula  must  correspond  to  the  back  of  the  child,  the  clavicle  to  its 
abdomen  ;  and,  by  feeling  one  or  the  other,  we  know  whether  we  have 
to  do  with  a  dorso-anterior  or  dorso-posterior  position.  If  we  cannot 
satisfactorily  determine  the  position  by  these  means,  it  is  quite  legiti- 
mate practice  to  bring  down  the  arm  carefully,  provided  the  membranes 
are  ruptured,  so  as  to  examine  the  hand,  which  will  be  easily  recognized 
as  right  or  left.  This  expedient  will  decide  the  point ;  but  it  is  one 
which  it  is  better  to  avoid,  if  possible,  for  it  not  only  slightly  increases 
the  difficulty  of  turning,  although  perhaps  not  very  materially,  but  the 
arm  might  possibly  be  injured  in  the  endeavor  to  bring  it  down. 

The  only  part  of  the  body  likely  to  be  taken  for  the  shoulder  is  the 
breech  ;  but  in  that  its  larger  size,  the  groove  in  which  the  genital 
organs  lie,  the  second  prominence  formed  by  the  other  buttock,  and  the 
sacral  spinous  processes,  are  sufficient  to  prevent  a  mistake. 

2.  The  elbow  is  rarely  felt  at  the  os,  and  may  be  readily  recognized 
by  the  sharp  prominence  of  the  olecranon,  situated  between  two  lesser 
prominences,  the  condyles.     As  the  elbow  always  points  toward  the 
feet,  the  position  of  the  foetus  can  be  easily  ascertained. 

3.  The  hand  is  easy  to  recognize,  and  can  only  be  confounded  with 
the  foot.     It  can  be  distinguished  by  its  borders  being  of  the  same 
thick  ness,  by  the  fingers  being  wider  apart  and  more  readily  separated 
from  each  other  than  the  toes,  and  above  all  by  the  mobility  of  the 
thumb,  which  can  be  carried  across  the  palm,  and  placed  in  apposition 
with  each  of  the  fingers. 

It  is  not  difficult  to  tell  which  hand  is  presenting.  If  the  hand  be  in 
the  vagina,  or  beyond  the  vulva,  and  within  easy  reach,  we  recognize 
which  it  is  by  laying  hold  of  it  as  if  we  were  about  to  shake  hands.  If 
the  palm  lie  in  the  palm  of  the  practitioner's  hand,  with  the  two  thumbs 
in  apposition,  it  is  the  right  hand  ;  if  the  back  of  the  hand,  it  is  the 
left.  Another  simple  way  is  for  the  practioner  to  imagine  his  own 
hand  placed  in  precisely  the  same  position  as  that  of  the  foetus ;  and 
this  will  readily  enable  him  to  verify  the  previous  diagnosis.  A 
simple  rule  tells  us  how  the  body  of  the  child  is  placed,  for,  provided 
we  are  sure  the  hand  is  in  a  state  of  supination,  the  back  of  the  hand 
points  to  the  back  of  the  child,  the  palm  to  its  abdomen,  the  thumb  to 
the  head,  and  the  little  finger  to  the  feet. 

Mechanism. — It  is  perhaps  hardly  proper  to  talk  of  a  mechanism 
of  shoulder  presentations,  since,  if  left  unassisted,  they  almost  in- 
variably lead  to  the  gravest  consequences.  Still,  Nature  is  not  entirely 
at  fault  even  here,  and  it  is  well  to  study  the  means  she  adopts  to 
terminate  these  malpositions. 

Terminations  of  Shoulder  Presentation. — There  are  two  possible 
terminations  of  shoulder  presentation.  In  one,  known  as  spontaneous 
version,  some  other  part  of  the  foetus  is  substituted  for  that  originally 
presenting ;  in  the  other,  spontaneous  evolution,  the  foetus  is  expelled 
by  being  squeezed  through  the  pelvis,  without  the  originally  presenting 
part  being  withdrawn.  It  cannot  be  too  strongly  impressed  on  the 
mind  that  neither  of  these  can  be  relied  on  in  practice. 


342  LABOR. 

Spontaneous  version  may  occasionally  occur  before,  or  immediately 
after,  the  rupture  of  the  membranes,  when  the  foetus  is  still  readily 
movable  within  the  cavity  of  the  uterus.  A  few  authenticated  cases 
are  recorded  in  which  the  same  fortunate  issue  took  place  after  the 
shoulder  had  been  engaged  in  the  pelvic  brim  for  a  considerable  time, 
or  even  after  prolapse  of  the  arm ;  but  its  probability  is  necessarily 
much  lessened  under  such  circumstances.  Either  the  head  or  the 
breech  may  be  brought  down  to  the  os  in  place  of  the  original  pres- 
entation. 

The  precise  mechanism  of  spontaneous  version,  or  the  favoring 
circumstances,  are  not  sufficiently  understood  to  justify  any  positive 
statement  with  regard  to  it. 

Cazeaux  believed  that  it  is  produced  by  partial  or  irregular  contrac- 
tion of  the  uterus,  one  side  contracting  energetically,  while  the  other 
remains  inert,  or  only  contracts  to  a  slight  degree.  To  illustrate  how 
this  may  effect  spontaneous  version,  let  us  suppose  that  the  child  is 
lying  with  the  head  in  the  left  iliac  fossa.  Then  if  the  left  side  of  the 
uterus  should  contract  more  forcibly  than  the  right,  it  would  clearly 
tend  to  push  the  head  and  shoulder  to  the  right  side,  until  the  head 
came  to  present  instead  of  the  shoulder.  A  very  interesting  case  is 
related  by  Geneuil,1  in  which  he  was  present  during  spontaneous 
version,  in  the  course  of  which  the  breech  was  substituted  for  the  left 
shoulder  more  than  four  hours  after  the  rupture  of  the  membranes. 
In  this  case  the  uterus  was  so  tightly  contracted  that  version  was  im- 
possible. He  observed  the  side  of  the  uterus  opposite  the  head  con- 
tracting energetically,  the  other  remaining  flaccid,  and  eventually  the 
case  ended  without  assistance,  the  breech  presenting.  The  natural 
moulding  action  of  the  uterus,  and  the  greater  tendency  of  the  long 
axis  of  the  child  to  lie  in  that  of  the  uterus,  no  doubt  assist  the  trans- 
formation, and  much  must  depend  on  the  mobility  of  the  foetus  in  any 
individual  case. 

That  such  changes  often  take  place  in  the  latter  weeks  of  pregnancy, 
and  before  labor  has  actually  commenced,  is  quite  certain,  and  they  are 
probably  much  more  frequent  than  is  generally  supposed.  When  spon- 
taneous version  does  occur,  it  is,  of  course,  a  most  favorable  event ; 
and  the  termination  and  prognosis  of  the  labor  are  then  the  same  as  if 
the  head  or  breech  had  originally  presented. 

Spontaneous  Evolution. — The  mechanism  of  spontaneous  evolu- 
tion, since  it  was  first  cleajly  worked  out  by  Douglas,  has  been  so 
often  and  carefully  described  that  we  know  precisely  how  it  occurs. 
Although  every  now  and  then  a  case  is  recorded  in  which  a  living 
child  has  been  born  by  this  means,  such  an  event  is  of  extreme  rarity; 
and  there  is  no  doubt  of  the  accuracy  of  the  general  opinion,  that  spon- 
taneous evolution  can  only  happen  when  the  pelvis  is  unusually  roomy 
and  the  child  small ;  and  that  it  almost  necessarily  involves  the  death 
of  the  foetus;  on  account  of  the  immense  pressure  to  which  it  is  sub- 
jected. 

Two  varieties  are  described,  in  one  of  which  the  head  is  first  born, 

1  Annal.  de  Gynec.,  1876,  torn.  v.  p.  468. 


PRESENTATIONS    OF    SHOULDER,    ETC.  343 

• 

in  the  other  the  breech ;  in  both  the  originally  presenting  arm  remained 
prolapsed.  The  former  is  of  extreme  rarity,  and  is  believed  only  to 
have  happened  with  very  premature  children,  whose  bodies  were  small 
and  flexible,  and  when  traction  had  been  made  on  the  presenting  arm. 
Under  such  circumstances  it  can  hardly  be  called  a  natural  process, 
and  wre  may  confine  our  attention  to  the '  latter  and  more  common 
variety. 

FIG  123. 


Spontaneous  evolution.    (After  CHIARA.)    This  drawing  was  made  from  a  patient  who  died 
undelivered,  the  body  being  frozen  and  bisected. 

What  takes  place  is  as  follows :  The  presenting  arm  and  shoulder 
are  tightly  jammed  down,  as  far  as  is  possible,  by  the  uterine  contrac- 
ti<>iis,  and  the  head  becomes  strongly  flexed  on  the  shoulder.  As  much 
of  the  body  of  the  foetus  as  the  pelvis  will  contain  becomes  engaged, 
and  then  a  movement  of  rotation  occurs,  which  brings  the  body  of  the 
child  nearly  into  the  antero-posterior  diameter  of  the  pelvis  (Fig.  123). 
The  shoulder  projects  under  the  arch  of  the  pubis,  the  head  lying  above 
the  symphysis,  and  the  breech  near  the  sacro-iliac  synchondrosis.  It 
is  essential*  that  the  head  should  lie  forward  above  the  pubes,  so  that 
the  length  of  the  neck  may  permit  the  shoulder  to  project  under  the 
pubic  arch,  without  any  part  of  the  head  entering  the  pelvic  cavity. 
The  shoulder  and  neck  of  the  child  no\v  become  fixed  points,  around 


344  LABOR. 

• 

which  the  body  of  the  child  rotates,  and  the  whole  force  of  the  uterine 
contractions  is  expended  on  the  breech.  The  latter,  with  the  body, 
therefore,  becomes  more  and  more  depressed,  until,  at  last,  the  side  of 
the  thorax  reaches  the  vulva,  and,  followed  by  the  breech  and  inferior 
extremities,  is  slowly  pushed  out.  As  soon  as  the  limbs  are  born  the 
head  is  easily  expelled. 

The  enormous  pressure  to  which  the  body  is  subjected  in  this  process 
can  readily  be  understood.  As  regards  the  practical  bearings  of  this 
termination  of  shoulder  presentations,  all  that  need  be  said  is,  that,  if 
we  should  happen  to  meet  with  a  case  in  which  the  shoulder  and 
thorax  were  so  strongly  depressed  that  turning  was  impossible,  and  in 
which  it  seemed  that  Nature  was  endeavoring  to  effect  evolution,  we 
should  be  justified  in  aiding  the  descent  of  the  breech  by  traction  on 
the  groin,  before  resorting  to  the  difficult  and  hazardous  operation  of 
embryotomy  and  decapitation. 

Treatment. — It  is  unnecessary  to  describe  specially  the  treatment 
of  shoulder  presentation,  since  it  consists  essentially  in  performing  the 
operation  of  turning,  which  is  fully  described  elsewhere.  It  is  only 
needful  here  to  insist  on  the  advisability  of  performing  the  operation 
in  the  way  which  involves  the  least  interference  with  the  uterus. 
Hence,  if  the  nature  of  the  case  be  detected  before  the  membranes  are 
ruptured,  an  endeavor  should  be  made — and  ought  generally  to  suc- 
ceed— to  turn  by  external  manipulation  only.  If  we  can  succeed  in 
bringing  the  breech  or  head  over  'the  os  in  this  way,  the  case  will  be 
little  more  troublesome  than  an  ordinary  presentation  of  these  parts. 
Failing  in  this,  turning  by  combined  external  and  internal  manipula- 
tion should  be  attempted  ;  and  the  introduction  of  the  entire  hand 
should  be  reserved  for  those  more  troublesome  cases  in  which  the 
waters  have  long  drained  away,  and  in  which  both  these  methods  are 
inapplicable. 

Should  all  these  means  fail,  we  must  resort  to  the  mutilation  of  the 
child  by  embryulcia  or  decapitation,  probably  the  most  difficult  and 
dangerous  of  all  obstetric  operations.  In  fourteen  cases  in  the  United 
States  the  Csesarean  section  has  been  performed  under  these  circum- 
stances, with  a  successful  result  to  the  mother  in  ten.  In  seven  cases 
the  arm  protruded,  in  three  the  pelvis  was  small,  and  in  two  it  was 
deformed.  Three  of  the  women  were  subsequently  delivered  naturally.1 
[The  four  deaths  were  produced  as  follows :  Case  3  was  in  labor  ninety- 
six  hours,  three  days  under  a  midwife,  and  died  of  exhaustion  in  seven- 
teen hours.  Case  7  was  twenty-six  hours  in  labor,  and  had  been  under 
the  care  of  a  midwife,  who  had  given  ergot  freely ;  she  was  much  pros- 
trated, and  died  in  twelve  hours.  Case  9  would  in  all  probability 
have  recovered  had  she  not  risen  from  her  bed  on  the  third  day  to 
defend  her  mother  against  her  husband,  who  came  home  drunk.  The 
fright,  excitement,  and  exertion  caused  her  death  in  a  'few  hours.  Case 
13  was  three  days  in  labor,  and  ergot  was  largely  used  ;  forceps,  ver- 
sion, and  craniotomy  were  all  tried.  Death  came  on  the  tenth  day 
from  the  bursting  of  an  abscess  of  the  abdominal  wall  into  the  peri- 

1  Harris,  note  to  6th  American  edition. 


PRESENTATIONS    OF    SHOULDER,    ETC.  345 

toneal  cavity,  resulting  in  septic  peritonitis.  Case  11  was  operated 
upon  in  June,  1880 ;  was  up  and  at  work  in  a  month ;  became  preg- 
nant in  two  and  a  half  more,  and  bore  a  child  naturally  in  twelve  and 
a  half  mouths  after  the  operation.  The  uterine  wound  was  closed  with 
two  silver-wire  sutures. 

This  operation  certainly  promises  well  in  cases  of  impaction  with 
an  arm  protruding  where  there  has  been  no  deforming  pelvic  disease. 
With  the  new  conservative  method  such  cases  should  be  saved  in  large 
proportion  in  the  United  States.  Will  embryulcia  or  decapitation  be 
likely  to  succeed  as  well  in  this  country? — ED.] 

Complex  Presentations. — There  are  various  so-called  complex  pres- 
entations in  which  more  than  one  part  of  the  foetal  body  presents.  Thus 
we  may  have  a  hand  or  a  foot  presenting  with  the  head,  or  a  foot  and 
hand  presenting  simultaneously.  The  former  do  not  necessarily  give 
rise  to  any  serious  difficulty,  for  there  is  generally  sufficient  room  for 
the  head  to  pass.  Indeed,  it  is  unlikely  that  either  the  hand  or  foot 
should  enter  the  pelvic  brim  with  the  head,  unless  the  head  was  unusu- 
ally small,  or  the  pelvis  more  than  ordinarily  capacious.  As  regards 
treatment,  it  is,  no  doubt,  advisable  to  make  an  attempt  to  replace  the 
hand  or  foot  by  pushing  it  gently  above  the  head  in  the  intervals 
between  the  pains,  and  to  maintain  it  there  until  the  head  be  fully 
engaged  in  the  pelvic  cavity.  The  engagement  of  the  head  can  be 
hastened  by  abdominal  pressure,  which  will  prove  of  great  value. 
Failing  this,  all  we  can  do  is  to  place  the  presenting  member  at  the 
part  of  the  pelvis  where  it  will  least  impede  the  labor,  and  be  the  least 
subjected  to  pressure  ;  and  that  Avill  generally  be  opposite  the  temple 
of  the  child.  As  it  must  obstruct  the  passage  of  the  head  to  a  certain 
extent,  the  application  of  the  forceps  may  be  necessary.  When  the 
feet  and  hands  present  at  the  same  time,  in  addition  to  the  confusing 
nature  of  the  presentation  from  so  many  parts  being  felt  together,  there 
is  the  risk  of  the  hands  coming  down,  and  converting  the  case  into  one 
of  arm  presentation.  It  is  the  obvious  duty  of  the  accoucheur  to  pre- 
vent this  by  insuring  the  descent  of  the  feet,  and  traction  should  be 
made  on  them,  either  with  the  fingers  or  with  a  fillet,  until  their  descent, 
and  the  ascent  of  the  hands,  are  assured. 

Dorsal  Displacement  of  the  Arm. — In  connection  with  this  sub- 
ject may  be  mentioned  the  curious  dorsal  displacement  of  the  arm  first 
described  by  Sir  James  Simpson,1  in  which  the  forearm  of  the  child 
becomes  thrown  across  and  behind  the  neck.  The  result  is  the  forma- 
tion of  a  ridge  or  bar,  which  prevents  the  descent  of  the  head  into  the 
pelvis  by  hitching  against  the  brim  (Fig.  124).  The  difficulty  of 
diagnosis  is  very  great,  for  the  cause  of  obstruction  is  too  high  up  to 
be  felt.  But  if  we  meet  with  a  case  in  which  the  pelvis  is  roomy  and 
the  pains  strong,  and  yet  the  head  does  not  descend  after  an  adequate 
time,  a  full  exploration  of  the  cause  is  essential.  For  this  purpose  we 
would  naturally  put  the  patient  under  chloroform,  and  pass  the  hand 
sufficiently  high.  We  might  then  feel  the  arm  in  its  abnormal  posi- 
tion. That  was  what  took  place  in  a  case  under  my  own  care,  in 

i  Selected  Obstet.  Works,  vol.  1. 


346 


LABOR. 


which  I  failed  to  get  the  head  through  the  brim  with  the  forceps,  and 
eventually  delivered  by  turning.  The  same  course  was  adopted  by 
my  friend  Mr.  Jardine  Murray  in  a  similar  case.1  Simpson  advises 
that  the  arm  should  be  brought  down  so  as  to  convert  the  case  into  an 
ordinary  hand  and  head  presentation.  This,  if  the  arm  be  above  the 
brim,  must  always  be  difficult,  and  I  believe  the  simpler  and  more 
effective  plan  is  podalic  version.  A  similar  displacement  may  cause 
some  difficulty  in  breech  presentations,  and  after  turning  (Fig.  125). 
Delay  here  is  easier  of  diagnosis,  since  the  obstacle  to  the  expulsion 
will  at  once  lead  to  careful  examination.  By  carrying  the  body  of  the 
child  well  backward,  so  as  to  enable  the  finger  to  pass  behind  the 
symphysis  pubis  and  over  the  shoulder,  it  will  generally  be  easy  to 
liberate  the  arm. 


FIG.  124. 


FIG.  125. 


Dorsal  displacement  of  the  arm. 


Dorsal  displacement  of  the  arm  In  footling 
presentations.    (After  BARNES.) 


Prolapse  of  the  Umbilical  Cord. — It  occasionally  happens  that 
the  umbilical  cord  falls  down  past  the  presenting  part  (Fig.  126),  and 
is  apt  to  be  pressed  between  it  and  the  walls  of  the  pelvis.  The  conse- 
quence is  that  the  foetal  circulation  is  seriously  interfered  with,  and  the 
death  of  the  child  from  asphyxia  is  a  common  result.  Hence  prolapse 
of  the  funis  is  a  very  serious  complication  of  labor  in  so  far  as  the 
child  is  concerned. 

1  Med.  Times  and  Gaz.,  1861 


PRESENTATIONS    OF    SHOULDER,    ETC.  347 

Frequency. — Fortunately  it  is  not  a  very  frequent  occurrence. 
Churchill  calculates  that  out  of  over  105,000  deliveries  it  was  met 
with  once  in  240  cases,  and  Scanzoni  once  in  254.  Its  frequency 
varies  much  under  different  circumstances,  and  in  different  places. 
We  find  from  Churchill's  figures  a  remarkable  difference  in  the  pro- 
portional number  of  cases  observed  in  France,  England,  and  Germany 
— viz.,  1  in  446J,  1  in  207^,  and  1  in  156,  respectively.  Great  as  is 
the  proportion  referred  to  Germany  in  these  figures,  it  has  been  found 
to  be  exceeded  in  special  districts.  Thus  Engelmann  records  1  case  out 
of  94  labors  in  the  Lying-in  Hospital  at  Berlin,  and  Michaelis  1  in  90 
in  that  of  Kiel.  These  remarkable  differences  are  at  first  sight  not 
easy  to  account  for.  Dr.  Simpson  suggests,  with  considerable  show  of 
probability,  that  the  difference  in  frequency  in  England,  France,  and 


FIG.  126 


Prolapse  of  the  umbilical  cord. 


Germany  may  depend  on  the  varying  positions  in  which  lying-in 
women  are  placed  during  labor  in  each  country.  In  France,  where, 
although  the  patient  is  laid  on  her  back,  the  pelvis  is  kept  elevated, 
the  complication  occurs  least  frequently ;  in  England,  where  she  lies 
on  her  side,  more  often ;  and  in  Germany,  where  she  is  placed  on  her 
back  with  her  shoulders  raised,  most  often.  The  special  frequency  of 
prolapsed  funis  in  certain  districts,  as  in  Kiel,  is  supposed  by  Engel- 
mauu1  to  depend  on  the  prevalence  of  rickets,  and  consequently  of 
deformed  pelvis,  which  we  shall  presently  see  is  probably  one  of  the 
most  frequent  and  important  causes  of  the  accident. 

Prognosis. — With  regard  to  the  danger  attending  prolapsed  funis, 
as  far  as  the  mother  is  concerned,  it  may  be  said  to  be  altogether  unim- 
portant ;  but  the  universal  experience  of  obstetricians  points  to  the 

i  Amer.  Journ.  of  Obstet.,  1873-74,  vol.  vi.  pp.  409,  540. 


348  LABOR. 

great  risk  to  which  the  child  is  subjected.  Scanzoni  calculates  that  45 
per  cent,  only  of  the  children  were  saved ;  Churchill  estimated  the 
number  at  47  per  cent. ;  thus,  under  the  most  favorable  circumstances, 
this  complication  leads  to  the  death  of  more  than  half  the  children. 
Engelmann  found  that  out  of  202  vertex  presentations  only  36  per 
cent,  of  the  children  survived.  The  mortality  was  not  nearly  so  great 
in  other  presentations ;  68  per  cent,  of  the  cases  in  which  the  child  pre- 
sented with  the  feet  were  saved,  and  50  per  cent,  in  original  shoulder 
presentations.  The  reason  of  this  remarkable  difference  is,  doubtless, 
that  in  vertex  presentations  the  head  fits  the  pelvis  much  more  com- 
pletely, and  subjects  the  cord  to  much  greater  pressure ;  while  in  other 
presentations  the  pelvis  is  less  completely  filled,  and  the  interference 
with  the  circulation  in  the  cord  is  not  so  great.  Besides,  in  the  latter 
case  the  complication  is  detected  early,  and  the  necessary  treatment 
sooner  adopted. 

The  foetal  mortality  is  considerably  greater  in  first  labors — a  result 
to  be  expected  on  account  of  the  greater  resistance  of  the  soft  parts, 
and  the  consequent  prolongation  of  the  labor. 

The  causes  of  prolapse  of  the  funis  are  any  circumstances,  which 
prevent  the  presenting  part  accurately  fitting  the  pelvic  brim.  Hence 
it  is  much  more  frequent  in  face,  breech,  or  shoulder  than  in  vertex 
presentations,  and  is  relatively  more  common  in  footling  and  shoulder 
presentations  than  in  any  other.  Amongst  occasional  accidental  pre- 
disposing causes  may  be  mentioned  early  rupture  of  the  membranes, 
especially  if  the  amount  of  liquor  amnii  be  excessive,  as  the  sudden 
escape  of  the  fluid  washes  down  the  cord ;  undue  length  of  the  cord 
itself ;  or  an  unusually  low  placental  attachment.  Engelmann  attaches 
great  importance  to  slight  contraction  of  the  pelvis,  and  states  that  in 
the  Berlin  Lying-in  Hospital,  where  accurate  measurements  of  the 
pelvis  were  taken  in  all  cases,  it  was  almost  invariably  found  to  exist. 
The  explanation  is  evident,  since  one  of  the  first  results  of  pelvic  con- 
traction is  to  prevent  the  ready  engagement  of  the  presenting  part  in 
the  pelvic  brim. 

The  diagnosis  of  cord  presentation  is  generally  devoid  of  difficulty ; 
but  if  the  membranes  are  still  unruptured,  it  may  not  always  be  quite 
easy  to  determine  the  precise  nature  of  the  soft  structures  felt  through 
them,  as  they  recede  from  the  touch.  If  the  pulsations  of  the  cord 
can  be  felt  through  the  membranes,  all  difficulty  is  removed.  After 
the  membranes  are  ruptured,  there  is  nothing  for  which  it  can  well  be 
mistaken. 

The  important  point  to  determine  in  such  a  case  is  whether  the  cord 
be  pulsating  or  not;  for  if  pulsations  have  entirely  ceased,  the  inference 
is  that  the  child  is  dead,  and  the  case  may  then  be  left  to  Kature  without 
further  interference.  It  is  of  importance,  however,  to.  be  careful ;  for, 
if  the  examination  be  made  during  a  pain,  the  circulation  might  be 
only  temporarily  arrested.  The  examination,  therefore,  should  be 
made  during  an  interval,  and  a  loop  of  the  cord  pulled  down,  if 
necessary,  to  make  ourselves  absolutely  certain  on  this  point. 

The  amount  of  the  prolapse  varies  much.  Sometimes  only  a  knuckle 
of  the  cord,  so  small  as  to  escape  observation,  is  engaged  between  the 


PRESENTATIONS    OF    SHOULDER,    ETC. 


349 


pelvis  and  presenting  part.  Under  such  circumstances  the  child  may 
be  sacrificed  without  any  suspicion  of  danger  having  arisen.  More 
often  the  amount  prolapsed  is  considerable  ;  sometimes  so  as  to  lie  in 
the  vagina  in  a  long  loop,  or  even  to  protrude  altogether  beyond  the 
vulva. 

Treatment. — In  the  treatment  the  great  indication  is  to  prevent 
the  cord  from  being  unduly  pressed  on,  and  all  our  endeavors  must 
have  this  object  in  view.  If  the  presentation  be  detected  before  the 
full  dilatation  of  the  cervix,  and  when  the  membranes  are  unruptured, 
we  must  try  to  keep  the  cord  out  of  the  way ;  to  preserve  the  mem- 
branes intact  as  long  as  possible,  since  the  cord  is  tolerably  protected 
as  long  as  it  is  surrounded  by  the  liquor  amnii ;  and  to  secure  the 
complete  dilatation  of  the  os,  so  that  the  presenting  part  may  engage 
rapidly  and  completely. 

Much  may  be  done  at  this  time  by  the  postural  treatment,  Avhich 
we  owe  chiefly  to  the  ingenuity  of  Dr.  T.  Gaillard  Thomas,  of  New 
York,  whose  writings  familiarized  the  profession  with  it,  although  it 
appears  that  a  somewhat  similar  plan  had  been  occasionally  adopted 
previously.  Dr.  Thomas's  method  is  based  on  the  principle  of  caus- 
ing the  cord  to  slip  back  into  the  uterine  cavity  by  its  own  weight. 
For  this  purpose  the  patient  is  placed  on  her  hands  and  knees,  with 
the  hips  elevated,  and  the  shoulders  resting  on  a  lower  level  (Fig. 
127).  The  cervix  is  then  no  longer  the  most  dependent  portion  of  the 

FIG.  127. 


Postural  treatment  of  prolapse  of  the  cord. 

uterus,  and  the  anterior  wall  of  the  uterus  forms  an  inclined  plane 
down  which  the  cord  slips.  The  success  of  this  manoeuvre  is  some- 
times very  great,  but  by  no  means  always  so.  It  is  most  likely  to 
succeed  when  the  membranes  are  unruptured.  If,  when  adopted,  the 
cord  slip  away,  and  the  os  be  sufficiently  dilated,  the  membranes  may 
be  ruptured,  and  engagement  of  the  head  produced  by  properly 
applied  uterine  pressure.  Sometimes  the  position  is  so  irksome  that 
it  is  impossible  to  resort  to  it.  Postural  treatment  is  not  even  then 
altogether  impossible,  for  by  placing  the  patient  on  the  side  opposite 


350 


LABOR. 


FIG.  128. 


to  that  of  the  prolapse,  so  as  to  relieve  the  cord  as  much  as  possible 
from  pressure,  and  at  the  same  time  elevating  the  hips  by  a  pillow, 
it  may  slip  back.  Even  after  the  membranes  are  ruptured,  postural 
treatment  in  one  form  or  another  may  succeed ;  and,  as  it  is  simple 
and  harmless,  it  should  certainly  be  always  tried.  Attempts  at  repo- 
sition, by  one  or  other  method  described  below,  may  also  occasionally 
be  facilitated  by  trying  them  when  the  patient  is  placed  in  the  knee- 
shoulder  position. 

Failing  by  postural  treatment,  or  in  combination  with  it,  it  is  quite 
legitimate  to  make  an  attempt  to  place  the  cord  beyond  the  reach  of 
dangerous  pressure  by  other  methods.  Unfortunately  reposition  is 
too  often  disappointing,  difficult  to  effect,  and  very  frequently,  even 
when  apparently  successful,  shortly  followed  by  a  fresh  descent  of  the 
cord.  Provided  the  os  be  fully  dilated  and  the  presenting  head 
engaged  in  the  pelvis  (for  reposition  may  be  said  to  be  hopeless  when 
any  other  part  presents),  perhaps  the  best  way  is  to  attempt  it  by  the 
hand  alone.  Probably  the  simplest  and  most  effectual  method  is  that 
recommended  by  McClintock  and  Hardy,  who  advise  that  the  patient 
should  lie  on  the  opposite  side  to  the  prolapsed  cord,  which  should 
then  be  drawn  towrard  the  pubes  as  being  the  shallowest  part  of  the 
pelvis.  Two  or  three  fingers  may  then  be  used  to 
push  the  cord  past  the  head,  and  as  high  as  they 
can  reach.  They  must  be  kept  in  the  pelvis  until 
a  pain  comes  on,  and  then  very  gently  withdrawn, 
in  the  hope  that  the  cord  may  not  again  prolapse. 
During  the  pain  external  pressure  may  very  prop- 
erly be  applied  to  favor  descent  of  the  head.  This 
manoeuvre  may  be  repeated  during  several  suc- 
cessive pains,  and  may  eventually  succeed.  The 
attempt  to  hook  the  cord  over  the  fetal  limbs,  or  to 
place  it  in  the  hollow  of  the  neck,  recommended 
in  many  works,  involves  so  deep  an  introduction 
of  the  hand  that  it  is  obviously  impracticable. 

Various  complex  instruments  have  been  in- 
vented to  aid  reposition  (Fig.  128),  but  even  if 
wre  possessed  them  they  are  not  likely  to  be  at 
hand  when  the  emergency  arises.  A  simple  in- 
strument may  be  improvised  out  of  an  ordinary 
male  elastic  catheter,  by  passing  the  two  ends  of 
a  piece  of  string  through  it,  so  as  to  leave  a  loop 
emerging  from  the  eye  of  the  catheter.  This  is 
passed  through  the  loop  of  prolapsed  cord,  and 
then  fixed  in  the  eye  of  the  catheter  by  means  of 
the  stilette.  The  cord  is  then  pushed  up  into  the 
uterine  cavity  by  the  catheter,  and  liberated  by 
withdrawing  the  stilette.  Another  simple  instru- 
ment may  be  made  by  cutting  a  hole  in  a  piece  of 
whalebone.  A  piece  of  tape  is  then  passed  through 
the  loop  of  the  cord  and  the  ends  threaded  through  the  eye  cut  in  the 
whalebone.  By  tightening  the  tape  the  whalebone  is  held  in  close 


Braun's  apparatus  for 
replacing  the  cord. 


PROLONGED    AND    PRECIPITATE    LABORS.  351 

apposition  to  the  cord,  and  the  whole  is  passed  as  high  as  possible  into 
the  uterine  cavity.  The  tape  can  easily  be  liberated  by  pulling  one 
end.  If  preferred,  the  cord  can  be  tied  to  the  whalebone,  which  is 
left  in  utero  until  the  child  is  born.  Nothing  need  be  said  as  to  the 
various  other  methods  adopted  for  keeping  up  the  cord,  such  as  the 
insertion  of  pieces  of  sponge,  or  tying  the  cord  in  a  bag  of  soft  leather, 
since  they  are  generally  admitted  to  be  quite  useless. 

It  only  too  often  happens  that  all  endeavors  at  reposition  fail.  The 
subsequent  treatment  must  then  be  guided  by  the  circumstances  of  the 
case.  If  the  pelvis  be  roomy,  and  the  pains  strong,  especially  in  a 
multipara,  we  may  often  deem  it  advisable  to  leave  the  case  to  Nature, 
in  the  hope  that  the  head  may  be  pushed  through  before  pressure  on 
the  cord  has  had  time  to  prove  fatal  to  the  child.  Under  such  circum- 
stances the  patient  should  be  urged  to  bear  down,  and  the  descent  of  the 
head  be  promoted  by  uterine  pressure,  so  as  to  get  the  second  stage 
completed  as  soon  as  possible.  If  the  head  be  within  easy  reach,  the 
application  of  the  forceps  is  quite  justifiable,  since  delay  must  neces- 
sarily involve  the  death  of  the  child.  During  this  time  the  cord  should 
be  placed,  if  possible,  opposite  one  or  the  other  sacro-iliac  synchon- 
drosis  according  to  the  position  of  the  head,  as  being  the  part  of  the 
pelvis  where  there  is  most  room,  and  pressure  would  consequently 
be  least  prejudicial.  If  we  have  to  do  Avith  a  case  in  which  the  head 
has  not  descended  into  the  pelvis,  and  postural  treatment  and  re- 
position have  both  failed,  provided  the  os  be  fully  dilated,  and  other 
circumstances  be  favorable,  turning  would  undoubtedly  offer  the  best 
chance  to  the  child.  This  treatment  is  strongly  advocated  by  Engel- 
mann,  who  found  that  70  per  cent,  of  the  children  delivered  in  this 
way  were  saved.  There  can  be  no  question  that,  so  far  as  the  inter- 
ests of  the  child  are  concerned,  it  is,  under  the  circumstances  indicated, 
by  far  the  best  expedient.  Turning,  however,  is  by  no  means  always 
devoid  of  a  certain  risk  to  the  mother,  and  the  performance  of  the 
operation,  in  any  particular  case,  must  be  left  to  the  judgment  of  the 
practitioner.  A  fully  dilated  os,  with  membranes  uuruptured,  so  that 
version  could  be  performed  by  the  combined  method  without  the 
introduction  of  the  hand  into  the  uterus,  would  be  unquestionably  the 
most  favorable  state.  If  it  be  not  deemed  proper  to  resort  to  it,  all 
that  can  be  done  is  to  endeavor  to  save  the  cord  from  pressure  as  much 
as  possible,  by  one  or  another  of  the  methods  already  mentioned. 


CHAPTER    IX. 

PROLONGED  AND  PRECIPITATE  LABORS. 

AMONG  the  difficulties  connected  with  parturition  there  are  none  of 
more  frequent  occurrence,  and  none  requiring  more  thorough  knowl- 
edge of  the  physiology  and  pathology  of  labor,  than  those  arising  from 


352  LABOR. 

deficient  or  irregular  action  of  the  expulsive  powers.  The  importance 
of  studying  this  class  of  labors  will  be  seen  when  we  consider  the 
numerous  and  very  diverse  causes  which  produce  them. 

Evil  Effects  of  Prolonged  Labor. — That  the  mere  prolongation 
of  labor  is  in  itself  a  serious  thing,  is  becoming  daily  more  and  more 
an  acknowledged  axiom  of  midwifery  practice ;  and  that  this  is  so  is 
evident  when  we  contrast  the  statistical  returns  of  such  institutions  as 
the  Rotunda  Lying-in  Hospital  of  late  years,  with  those  which  were 
published  some  twenty  or  thirty  years  ago.  It  may  be  fairly  assumed 
that  the  practice  of  the  distinguished  heads  of  that  well-known  school 
represents  the  most  advanced  and  scientific  opinions  of  the  day.  When 
we  find  that,  less  than  thirty  years  ago,  forceps  were  not  used  more 
than  once  in  310  labors,  while,  according  to  the  report  for  1873,  the 
late  master  applied  them  once  in  8  labors,  it  is  apparent  how  great  is 
the  change  which  has  taken  place. 

Labor  may  be  prolonged  from  an  immense  number  of  causes,  the 
principal  of  which  will  require  separate  study.  Some  depend  simply 
on  defective  or  irregular  action  of  the  uterus ;  others  act  by  opposing 
the  expulsion  of  the  child,  as,  for  example,  undue  rigidity  of  the  par- 
turient passages,  tumors,  bony  deformity,  and  the  like.  Whatever  the 
source  of  delay,  a  train  of  formidable  symptoms  is  developed  which 
are  fraught  with  peril  both  to  the  mother  and  the  child.  As  regards 
the  mother,  they  vary  much  in  degree  and  in  the  rapidity  with  which 
they  become  established.  In  many  cases,  in  which  the  action  of  the 
uterus  is  slight,  it  may  be  long  before  serious  results  follow ;  while  in 
others,  in  which  a  strongly-acting  organ  is  exhausting  itself  in  futile 
endeavors  to  overcome  an  obstacle,  the  worst  signs  of  protraction  may 
come  on  with  comparative  rapidity. 

The  stage  of  labor  in  which  delay  occurs  has  a  marked  effect 
in  the  production  of  untoward  symptoms.  It  is  a  well-established 
fact  that  prolongation  is  of  comparatively  small  consequence  to  either 
the  mother  or  child  in  the  first  stage,  when  the  membranes  are  still 
intact,  and  when  the  soft  parts  of  the  mother,  as  well  as  the  body  of 
the  child,  are  protected  by  the  liquor  amnii  from  injurious  pressure; 
whereas  if  the  membranes  have  ruptured,  prolongation  becomes  of  the 
utmost  importance  to  both  as  soon  as  the  head  has  entered  the  pelvis, 
when  the  uterus  is  strongly  excited  by  reflex  stimulation,  when  the 
maternal  soft  parts  are  exposed  to  continuous  pressure,  and  when  the 
tightly  contracted  uterus  presses  firmly  on  the  foetus  and  obstructs  the 
placenta!  circulation.  It  is  in  reference  to  the  latter  class  of  cases  that 
the  change  of  practice,  already  alluded  to,  has  taken  place,  with  the 
most  beneficial  results  both  to  mother  and  child. 

It  must  not  be  assumed,  however,  that  prolongation  of  labor  is 
never  of  any  consequence  until  the  second  stage  has  commenced.  The 
fallacy  of  such  an  opinion  was  long  ago  shown  by  Simpson,  who 
proved  in  the  most  conclusive  way,  that  both  the  maternal  and  foetal 
mortality  were  greatly  increased  in  proportion  to  the  entire  length  of 
the  labor ;  and  all  practical  accoucheurs  are  familiar  with  cases  in  which 
symptoms  of  gravity  have  arisen  before  the  first  stage  is  concluded. 
Still,  relatively  speaking,  the  opinion  indicated  is  undoubtedly  correct. 


PROLONGED    AND    PRECIPITATE    LABORS.  353 

In  the  present  chapter  we  have  to  do  only  with  those  causes  of 
delay  connected  with  the  expulsive  powers.  Inasmuch,  however,  as 
the  injurious  effects  of  protraction  are  similar  in  kind  whatever  be 
the  cause,  it  .will  save  needless  repetition  if  we  consider,  once  for  all, 
the  train  of  symptoms  that  arise  whenever  labor  is  unduly  prolonged. 

Delay  in  the  First  Stage  is  Rarely  Serious. — As  long  as  the 
delay  is  in  the  first  stage  only,  with  rare  exceptions,  no  symptoms  of 
real  gravity  arise  for  a  length  of  time;  it  may  be  even  lor  days. 
There  is  often,  however,  a  partial  cessation  of  the  pains,  which,  in 
consequence  of  temporary  exhaustion  of  nervous  force,  may  even 
entirely  disappear  for  many  consecutive  hours.  Under  such  circum- 
stances, after  a  period  of  rest,  either  natural  or  produced  by  suitable 
sedatives,  they  recur  with  renewed  vigor. 

Symptoms  of  Protraction  in  the  Second  Stage. — A  similar 
temporary  cessation  of  the  pains  may  often  be  observed  after  the  head 
has  passed  through  the  os  uteri,  to  be  also  followed  by  renewed  vigor- 
ous action  after  rest.  But  now  any  such  irregularity  must  be  much 
more  anxiously  watched.  In  the  majority  of  cases  any  marked  alter- 
ation in  the  force  and  frequency  of  the  pains  at  this  period  indicates 
a  much  more  serious  form  of  delay,  which  in  no  long  time  is  accom- 
panied by  grave  general  symptoms.  The  pulse  begins  to  rise,  the  skin 
to  become  hot  and  dry,  the  patient  to  be  restless  and  irritable.  The 
longer  the  delay,  and  the  more  violent  the  efforts  of  the  uterus  to 
overcome  the  obstacle,  the  more  serious  does  the  state  of  the  patient 
become.  The  tongue  is  loaded  with  fur,  and  in  the  worst  cases  dry 
and  black ;  nausea  and  vomiting  often  become  marked ;  the  vagina 
feels  hot  and  dry,  the  ordinary  abundant  mucous  secretion  being 
absent ;  in  severe  cases  it  may  be  much  swollen,  and  if  the  presenting 
part  be  firmly  impacted,  a  slough  may  even  form.  Should  the  patient 
still  remain  undelivered,  all  these  symptoms  become  greatly  intensi- 
fied ;  the  vomiting  is  incessant,  the  pulse  is  rapid  and  almost  imper- 
ceptible, low  muttering  delirium  supervenes,  and  the  patient  eventually 
dies  with  all  the  worst  indications  of  profound  irritation  and  exhaustion. 

So  formidable  a  train  of  symptoms,  or  even  the  slighter  degrees  of 
them,  should  never  occur  in  the  practice  of  the  skilled  obstetrician ; 
and  it  is  precisely  because  a  more  scientific  knowledge  of  the  process 
of  parturition  has  taught  the  lesson  that,  under  such  circumstances, 
prevention  is  better  than  cure,  that  earlier  interference  has  become  so 
much  more  the  rule. 

Those  who  taught,  that  nothing  should  be  done  until  Nature  had 
had  every  possible  chance  of  effecting  delivery,  and  who,  therefore, 
allowed  their  patients  to  dcag  on  through  many  weary  hours  of  labor, 
at  the  expense  of  great  exhaustion  to  themselves,  and  imminent  risk 
to  their  offspring,  made  much  capital  out  of  the  time-honored  maxim 
that  "  meddlesome  midwifery  is  bad.'7  When  this  proverb  is  applied 
to  restrain  the  rash  interference  of  the  ignorant,  it  is  of  undeniable 
value ;  but  when  it  is  quoted  to  prevent  the  scientific  action  of  the 
experienced,  who  know  precisely  when  and  why  to  interfere,  and  who 
have  acquired  the  indispensable  mechanical  skill,  it  is  sadly  mis- 
applied. 

23 


354  LABOR. 

State  of  the  Uterus  in  Protracted  Labor. — The  nature  of  the 
pains  and  the  state  of  the  uterus,  in  cases  of  protracted  labor,  are 
peculiarly  worthy  of  study,  and  have  been  very  clearly  pointed  out 
by  Dr.  Braxton  Hicks.1  He  shows  that,  when  the  pains  have  appar- 
ently fallen  off  and  become  few  and  feeble,  or  have  entirely  ceased, 
the  uterus  is  in  a  state  of  continuous  or  tonic  contraction,  and  that  the 
irritation  resulting  from  this  is  the  chief  cause  of  the  more  marked 
symptoms  of  powerless  labor.  If,  in  a  case  of  the  kind,  the  uterus 
be  examined  by  palpation,  it  will  be  found  firmly  contracted  between 
the  pains.  The  correctness  of  this  observation  is  beyond  question, 
and  it  will,  no  doubt,  often  be  an  important  guide  in  treatment. 
Under  such  circumstances  instrumental  interference  is  imperatively 
demanded. 

Causes. — In  considering  the  causes  of  protracted  labor,  it  will  be 
w^ell  first  to  discuss  those  which  affect  the  expulsive  powers  alone, 
leaving  those  depending  on  morbid  states  of  the  passages  for  future 
consideration ;  bearing  in  mind,  however,  that  the  results,  as  regards 
both  the  mother  and  the  child,  are  identical,  whatever  may  be  the 
cause  ol  delay. 

The  general  constitutional  state  of  the  patient  may  materially  in- 
fluence the  force  and  efficiency  of  the  pains.  Thus  it  not  unfrequently 
happens  that  they  are  feeble  and  ineffective  in  women  of  very  weak 
constitution,  or  who  are  much  exhausted  by  debilitating  disease. 
Cazeaux  pointed  out  that  the  effects  of  such  general  conditions  are 
often  more  than  counterbalanced  by  flaccidity  and  want  of  resistance 
of  the  tissues,  so  that  there  is  less  obstacle  to  the  passage  of  the  child. 
Thus,  in  phthisical  patients  reduced  to  the  last  stage  of  exhaustion, 
labor  is  not  uufrequently  surprisingly  easy. 

Long  residence  in  tropical  climates  causes  uterine  inertia,  in  conse- 
quence of  the  enfeebled  nervous  power  it  produces.  It  is  a  common 
observation  that  European  residents  in  India  are  peculiarly  apt  to 
suffer  from  post-partum  hemorrhage  from  this  cause.  The  general 
mode  of  life  of  patients  has  an  unquestionable  effect ;  and  it  is  certain 
that  deficient  and  irregular  uterine  action  is  more  common  in  women 
of  the  higher  ranks  of  society,  who  lead  luxurious,  enervating  lives, 
than  in  women  whose  habits  are  of  a  more  healthy  character. 

Tyler  Smith  lays  much  stress  on  frequent  childbearing  as  a  cause 
of  inertia,  pointing  out  that  a  uterus  which  has  been  very  frequently 
subjected  to  the  changes  connected  with  pregnancy,  is  unlikely  to  be 
in  a  typically  normal  condition.  It  is  doubtful,  however,  whether  the 
uterus  of  a  perfectly  healthy  woman  is  affected  in  this  way ;  certainly, 
if  childbearing  had  undermined  her  general  health,  the  labors  are 
likely  to  be  modified  also. 

Age  has  a  decided  effect.  In  the  very  young  the  pains  are  apt  to  be 
irregular,  on  account  of  imperfect  development  of  the  uterine  muscles. 
Labor  taking  place  for  the  first  time  in  women  advanced  in  life  is  also 
apt  to  be  tedious,  hut  not  by  any  means  so  invariably  as  is  generally 
believed.  The  apprehensions  of  such  patients  are  often  agreeably 

1  Obst.  Trans.,  1867,  vol.  ix.  p.  207. 


PROLONGED    AND    PRECIPITATE    LABORS.  355 

falsified,  and  where  delay  does  occur,  it  is  probably  more  ofter  referable 
to  rigidity  and  toughness  of  the  parturient  passages  than  to  feebleness 
of  the  pains. 

Morbid  states  of  the  primse  vise  frequently  cause  irregular,  painful, 
and  feeble  contractions.  A  loaded  state  of  the  rectum  has  a  remarkable 
influence,  as  evidenced  by  the  sudden  and  distinct  change  in  the  char- 
acter of  the  labor  which  often  follows  the  use  of  suitable  remedies. 
Undue  distention  of  the  bladder  may  act  in  the  same  way,  more  espe- 
cially in  the  second  stage.  When  the  urine  has  been  allowed  to  accu- 
mulate unduly,  the  contraction  of  "the  accessory  muscles  of  parturition 
often  causes  such  intense  suffering,  by  compressing  the  distended  viscus, 
that  the  patient  is  absolutely  unable  to  bear  down.  Hence  the  labor 
is  carried  on  by  uterine  contractions  alone,  slowly,  and  at  the  expense 
of  much  suffering.  A  similar  interference  with  the  action  of  the 
accessory  muscles  is  often  produced  by  other  causes.  Thus  if  labor 
comes  on  when  the  patient  is  suffering  from  bronchitis  or  other  chest 
disease,  she  may  be  quite  unable  to  fix  the  chest  by  a  deep  inspiration, 
and  the  diaphragm  and  other  accessory  muscles  cannot  act.  In  the 
same  way  they  may  be  prevented  from  acting  when  the  abdomen  is 
occupied  by  an  ovarian  tumor,  or  by  ascitic  fluid. 

Mental  conditions  have  a  very  marked  effect.  This  is  so  commonly 
observed  that  it  is  familiar  to  the  merest  beginner  in  midwifery  prac- 
tice. The  fact  that  the  pains  often  diminish  temporarily  on  the 
entrance  of  the  accoucheur  is  known  to  every  nurse ;  and  so  also  undue 
excitement,  the  presence  of  too  many  people  in  the  room,  overmuch 
talking,  have  often  the  same  prejudicial  effect.  Depression  of  mind, 
as  in  unmarried  women,  and  fear  and  despondency  in  women  who  have 
looked  forward  with  apprehension  to  the  labor,  are  also  common  causes 
of  irregular  and  defective  action. 

Undue  distention  of  the  uterus  from  an  excessive  amount  of  liquor 
amnii  not  unfrequently  retards  the  first  stage,  by  preventing  the  uterus 
from  contracting  efficiently.  When  this  exists,  the  pains  are  feeble 
and  have  little  effect  in  dilating  the  cervix  beyond  a  certain  degree. 
This  cause  may  be  suspected  when  undue  protraction  of  the  first  stage 
is  associated  with  an  unusually  large  size  and  marked  fluctuation  of 
the  uterine  tumor,  through  which  the  foetal  limbs  cannot  be  made  out 
on  palpation.  On  vaginal  examination  the  lower  segment  of  the 
uterus  will  be  found  to  be  very  rounded  and  prominent,  while  the 
bag  of  membranes  will  not  bulge  through  the  os  during  the  acme  of 
the  pain. 

A  somewhat  similar  cause  is  undue  obliquity  of  the  uterus,  which 
prevents  the  pains  acting  to  the  best  mechanical  advantage,  and  often 
retards  the  entry  of  the  presenting  part  into  the  brim.  The  most 
common  variety  is  anteversion,  resulting  from  undue  laxity  of  the 
abdominal  parietes,  which  is  especially  found  in  women  who  have 
borne  many  children.  Sometimes  this  is  so  excessive  that  the  fundus 
lies  oves  the  pubes,  and  even  projects  downward  toward  the  patient's 
knees.  The  consequence  is,  that,  when  labor  sets  in,  unless  corrective 
means  be  taken,  the  pains  force  the  head  against  the  sacrum,  instead 
of  directing  it  into  the  axis  of  the  pelvic  inlet.  Another  common 


356  LABOR. 

deviation  is  lateral  obliquity,  a  certain  degree  of  which  exists  in  almost 
all  cases,  but  sometimes  it  occurs  to  an  excessive  degree.  Either  of 
these  states  can  readily  be  detected  by  palpation  and  vaginal  examina- 
tion combined.  In  the  former  the  os  may  be  so  high  up,  and  tilted  so 
far  backward,  that  it  may  be  at  first  difficult  to  reach  it  at  all. 

Irregular  and  Spasmodic  Pains. — Besides  being  feeble,  the  uterine 
contractions,  especially  in  the  first  stage,  are  often  irregular  and  spas- 
modic, intensely  painful,  but  produciug  little  or  no  effect  on  the 
progress  of  the  "labor.  This  kind  of  case  has  been  already  alluded  to 
in  treating  of  the  use  of  anaesthetics  (p.  308),  and  is  very  common  in 
highly  nervous  and  emotional  women  of  the  upper  classes.  In  such 
cases  cocaine  has  been  of  late  used  as  a  local  application  with  decided 
benefit.  It  appears  to  act  by  deadening  the  pain  resulting  from  the 
stretching  of  the  nerves  of  the  cervix,  or  from  slight  cervical  lacera- 
tions. It  has  no  effect  in  relieving  the  suffering  caused  by  uterine 
contraction.1  It  has  been  applied  by  means  of  a  cotton-wool  tampon 
steeped  in  a  2  per  cent,  solution,  and  placed  against  the  os.  A  much 
better  way  of  using  it  is  by  "  Moore's  cones"1  made  with  cacao-butter, 
one  of  which  is  placed  on  the  examining  finger  like  a  thimble,  and 
inserted  within  the  os,  where  it  rapidly  melts.  Antipyrine  has  been 
frequently  used  in  this  kind  of  labor  as  a  uterine  sedative,  but  its 
beneficial  effects  appear  to  be  doubtful.  Auvard  and  Lefebvre,3  who 
have  carefully  studied  and  reported  cases,  come  to  the  conclusion  that 
it  cannot  be  compared  in  efficacy  with  chloral,  although  occasionally 
useful.  It  may  be  given  in  a  dose  of  fifteen  grains,  repeated  in  two 
hours.  Such  irregular  contractions  do  not  necessarily  depend  on 
mental  causes  alone,  and  they  often  follow  conditions  producing  irrita- 
tion, such  as  loaded  bowels,  too  early  rupture  of  the  membranes,  and 
the  like.  Dr.  Trenholme,  of  Montreal,4  believes  that  such  irregular 
pains  most  frequently  depend  on  abnormal  adhesions  between  the 
decidua  and  the  uterine  walls,  which  interfere  with  the  proper  dilata- 
tion of  the  os,  and  he  has  related  some  interesting  cases  in  support  of 
this  theory. 

Treatment. — The  mere  enumeration  of  these  various  causes  of  pro- 
tracted labor  will  indicate  the  treatment  required.  Some  of  them, 
such  as  the  constitutional  state  of  the  patient,  age,  or  mental  emotion, 
it  is,  of  course,  beyond  the  power  of  the  practitioner  to  influence  or 
modify ;  but  in  every  case  of  feeble  or  irregular  uterine  action,  a  careful 
investigation  should  be  made  with  the  view  of  seeing  if  any  removable 
cause  exist.  For  example,  the  effect  of  a  large  enema,  when  we  sus- 
pect the  existence  of  a  loaded  rectum,  is  often  very  remarkable ;  the 
pains  frequently  almost  immediately  changing  in  character,  and  a  pre- 
viously lingering  labor  being  rapidly  terminated. 

Excessive  distention  of  the  uterus  can  only  be  treated  by  artificial 
evacuation  of  the  liquor  amnii ;  and  after  this  is  done,  the  character  of 
the  pains  often  rapidly  changes.  This  expedient  is  indeed  often  of 
considerable  value  in  cases  in  which  the  cervix  has  dilated  to  a  cer- 

1  "The  Value  of  Cocaine  iu  Obstetrics,"  by  John  Phillips,  M.A.,  M.D.    Lancet,  Nov.  26,  1887. 

*  Brit.  Med.  Journ.,  1885,  vol.  ii.  p.  1140. 

*  Arch,  de  Tocol..  1888,  p.  649,  and  1889,  p.  505. 
«  Obst.  Trans..  1873,  vol.  xiv.  p.  231. 


PROLONGED    AND    PRECIPITATE    LABORS.  357 

tain  extent,  but  in  which  no  further  progress  is  made,  especially  if  the 
bag  of  membranes  does  not  protrude  through  the  os  during  the  pains, 
and  the  cervix  itself  is  soft,  and  apparently  readily  dilatable.  Under 
such  circumstances,  rupture  of  the  membranes,  even  before  the  os  is 
fully  dilated,  is  often  very  useful. 

If  we  have  reason  to  suspect  morbid  adhesions  between  the  mem- 
branes and  the  uterine  walls,  an  endeavor  must  be  made  to  separate 
them  by  sweeping  the  finger  or  a  flexible  catheter  around  the  internal 
margin  of  the  os,  or  puncturing  the  sac.  The  former  expedient  has 
been  advocated  by  Dr.  Inglis,1  as  a  means  of  increasing  the  pains  when 
the  first  stage  is  very  tedious,  and  I  have  often  practised  it  with  marked 
success.  Treuholme's  observation  affords  a  rationale  of  its  action. 
The  manoeuvre  itself  is  easily  accomplished,  and,  provided  the  os  be 
not  very  high  in  the  pelvis,  does  not  give  any  pain  or  discomfort  to 
the  patient. 

Attention  should  always  be  paid  to  remedying  any  deviations  of  the 
uterus  from  its  proper  axis.  If  this  be  lateral,  the  proper  course  to 
pursue  is  to  make  the  patient  lie  on  the  opposite  side  to  that  toward 
which  the  organ  is  pointing.  In  the  more  common  anterior  deviation 
she  should  lie  on  her  back,  so  that  the  uterus  may  gravitate  toward 
the  spine,  and  a  firm  abdominal  bandage  should  be  applied.  This 
prevents  the  organ  from  falling  forward,  while  its  pressure  stimu- 
lates the  muscular  fibres  to  increased  action ;  hence  it  is  often  very 
serviceable  when  the  pains  are  feeble,  even  if  there*  be  no  antever- 
sion. 

In  a  frequent  class  of  cases,  especially  in  the  first  stage,  the  pains 
diminish  in  force  and  frequency  from  fatigue,  and  the  indication  then 
is  to  give  a  temporary  rest,  after  -which  they  recommence  with  renewed 
vigor.  Hence  an  opiate,  such  as  twenty  minims  of  Battley's  solution, 
which  often  acts  quickest  when  given  in  the  form  of  enema,  is  fre- 
quently of  the  greatest  possible  value.  If  this  secure  a  few  hours* 
sleep  the  patient  will  generally  awake  much  refreshed  and  invigorated. 
It  is  important  to  distinguish  this  variety  of  arrested  pain  from  that 
dependent  on  actual  exhaustion  ;  and  this  can  be  done  by  attention  to 
the  general  condition  of  the  patient,  and  especially  by  observing  that 
the  uterus  is  soft  and  flaccid  in  the  intervals  between  the  pains,  and 
that  there  is  none  of  the  tonic  contraction  indicated  by  persistent  hard- 
ness of  the  uterine  parietes.  When  the  pains  are  irregular,  spasmodic, 
and  excessively  painful,  without  producing  any  real  effect,  opiates  are 
also  of  great  service ;  and  it  is  under  such  circumstances  that  chloral 
is  especially  valuable. 

Oxytocic  Remedies. — Still  a  large  number  of  cases  will  arise  in 
which  the  absence  of  all  removable  causes  has  been  ascertained,  and  in 
which  the  pains  are  feeble  and  ineffective.  We  must  now  proceed  to 
discuss  their  management.  The  fault  being  the  want  of  sufficient  con- 
traction, the  first  indication  is  to  increase  the  force  of  the  pains.  Here 
the  so-called  oxytocie  remedies  come  into  action  ;  and,  although  a  large 
number  of  these  have  been  used  from  time  to  time,  such  as  borax, 

i  Sydenham  Society's  Year-book,  1367,  p.  899. 


358  LABOR. 

cinnamon,  quinine,  and  galvanism,  practically  the  only  one  in  which 
reliance  is  generally  placed  is  the  ergot  of  rye.  This  has  long  been 
the  favorite  remedy  for  deficient  uterine  action,  and  it  is  a  powerful 
stimulant  of  the  uterine  fibres.  It  has,  however,  very  serious  disad- 
vantages, and  it  is  very  questionable  whether  the  risks  to  both  mother 
and  child  do  not  more' than  counterbalance  any  advantages  attending 
its  use.  The  ergot  is  given  in  doses  of  fifteen  or  twenty  grains  of  the 
freshly  powdered  drug  infused  in  warm  water,  or  in  the  more  con- 
venient form  of  the  liquid  extract  in  doses  of  from  twenty  to  thirty 
minims,  or,  still  better,  in  the  form  of  ergotine  injected  hypodermi- 
cally,  three  to  four  minims  of  the  hypodermic  solution  being  used  for 
the  purpose.  In  about  fifteen  minutes  after  its  administration  the 
pains  generally  increase  greatly  in  force  and  frequency,  and  if  the 
head  be  low  in  the  pelvis,  and  if  the  soft  parts  offer  no  resistance,  the 
labor  may  be  rapidly  terminated. 

Were  its  use  always  followed  by  this  effect  there  would  be  little  or 
no  objection  to  its  administration.  The  pains,  however,  are  different 
from  those  of  natural  labor,  being  strong,  persistent,  and  constant.  Its 
effect,  indeed,  is  to  produce  that  .very  state  of  tonic  and  persistent 
uterine  contraction  which  has  already  been  pointed  out  as  one  of  the 
chief  dangers  of  protracted  labor.  Hence,  if  from  any  cause  the  exhibi- 
tion of  the  drug  be  not  followed  by  rapid  delivery,  a  condition  is  pro- 
duced which  is  serious  to  the  mother,  and  which  is  extremely  perilous 
to  the  child,  on  account  of  the  tonic  contraction  of  the  muscular  fibres 
obstructing  the  utero-placental  circulation.  Dr.  Hardy  found  that 
soon  the  foetal  pulsations  fall  to  100,  and,  if  delivery  be  long  delayed, 
they  commence  to  intermit.  He  also  observed  that  when  this  occurred 
the  child  was  always  born  dead,  and  found  that  the  number  of  still- 
born children  after  ergot  has  been  exhibited  was  very  large ;  for  out 
of  thirty  cases  in  which  he  gave  it  in  tedious  labor,  only  ten  of  the 
children  were  born  alive.  Xor  is  its  use  by  any  means  free  from 
danger  to  the  mother;  a  not  inconsiderable  number  of  cases  of  rupture 
of  the  uterus  have  been  attributed  to  its  incautious  use.  Hence,  if  it 
is  to  be  given  at  all,  it  is  obvious  that  it  must  be  with  strict  limita- 
tions, and  after  careful  consideration.  It  is  worthy  of  note  that  in  the 
Rotunda  Hospital  in  Dublin,  the  use  of  ergot  as  an  oxytocic  before 
delivery  has  been  prohibited  by  the  present  master. 

The  cardinal  point  to  remember  is  that  it  is  absolutely  contra-indi- 
cated unless  the  absence  of  all  obstacles  to  rapid  delivery  has  been 
ascertained.  Hence,  it  is  only  allowable  when  the  first  stage  is  over, 
and  the  os  fully  dilated ;  when  the  experience  of  former  labors  has 
proved  the  pelvis  to  be  of  ample  size ;  and  when  the  perineum  is  soft 
and  dilatable.  Perhaps,  as  has  been  suggested,  the  administration  of 
small  doses  of  from  five  to  ten  minims  of  the  liquid  extract  every  ten 
minutes,  until  more  energetic  action  sets  in,  might  obviate  some  of 
these  risks. 

The  use  of  quinine  as  an  oxytocic  deserves  much  more  attention 
than  it  has  generally  received.  I  frequently  employ  it  in  lingering 
labor  with  marked  benefit,  and  it  does  not  seem  to'  have  any  of  the 
bad  effects  of  ergot.  According  to  the  observations  of  Dr.  Albert  H. 


PKOLONQED    AND    PRECIPITATE    LABORS.  359 

Smith,  in  forty-two  cases  of  parturition,  it  presented  the  following 
peculiar  characteristics : 

It  has  no  power  in  itself  to  excite  uterine  contractions,  but  simply 
acts  as  a  general  stimulant  and  promoter  of  vital  energy  and  func- 
tional activity.  Dr.  R.  Doyle,  of  Trinidad,  recently  writes  to  point 
out  that  quinine  given  in  malarial  fever  is  constantly  observed  to  pro- 
duce uterine  contractions  and  abortion.1 

In  normal  labor  at  full  term,  its  administration  in  a  dose  of  fifteen 
grains  is  usually  followed  in  as  many  minutes  by  a  decided  increase  in 
the  force  and  frequency  of  the  uterine  contractions,  changing  in  some 
instances  a  tedious,  exhausting  labor  into  one  of  rapid  energy,  ad- 
vancing to  an  early  completion. 

It  promotes  the  permanent  tonic  contraction  of  the  uterus,  after  the 
expulsion  of  the  placenta ;  women  that  had  flooded  in  former  labors 
escaping  entirely,  there  not  having  been  an  instance  of  post-partum 
hemorrhage  in  the  whole  forty- two  cases. 

It  also  diminishes  the  lochial  flow  where  it  had  been  excessive  in 
former  labors,  the  change  being  remarked  upon  by  the  patients,  and 
consequently  lessens  the  severity  of  the  after-pains. 

Cinchonism  is  very  rarely  observed  as  an  effect  of  large  doses  in 
parturient  women.2 

Use  of  the  Paradic  Current. — The  faradic  current  applied  on 
either  side  of  the  uterine  tumor,  midway  between  the  anterior-superior 
spine  of  the  ilium  and  the  umbilicus,  has  recently  been  strongly  recom- 
mended by  Dr.  Kilner,3  not  only  as  a  means  of  increasing  uterine 
action,  but  of  alleviating  the  sufferings  of  childbirth.  I  have  tried  it 
in  several  cases,  but  am  not  satisfied  as  to  its  possessing  the  properties 
attributed  to  it. 

If  we  had  no  other  means  of  increasing  defective  uterine  contractions 
at  our  disposal,  and  if  the  choice  lay  only  between  the  use  of  ergot  and 
instrumental  delivery,  there  might  not  be  so  much  objection  to  a  cau- 
tious use  of  the  drug  in  suitable  cases.  We  have,  however,  a  means  of 
increasing  the  force  of  the  uterine  contractions  so  much  more  manage- 
able, and  so  much  more  resembling  the  natural  process,  that  I  believe 
it  to  be  destined  to  entirely  supersede  the  administration  of  ergot. 
This  is  the  application  of  manual  pressure  to  the  uterus  through  the 
abdomen,  an  expedient  that  has  of  late  years  been  much  used  in  Ger- 
many, and  has  begun  to  be  employed  in  English  practice.  I  believe, 
therefore,  that  ergot  should  be  chiefly  used  for  the  purpose  of  exciting 
uterine  contraction  after  delivery,  when  its  peculiar  property  of  pro- 
moting tonic  contraction  is  so  valuable,  and  that  it  should  rarely,  if  at 
all,  be  employed  before  the  birth  of  the  child. 

The  systematic  use  of  uterine  pressure  as  an  oxytocic  was  first  promi- 
nently brought  under  the  notice  of  the  profession  by  Kristeller,  under 
the  name  of  expressio  foetus,  although  it  has  been  used  in  varioua 
forms  from  time  immemorial.  Albucasis,  for  example,  was  clearly 
acquainted  with  its  use,  and  referred  to  it  in  the  following  terms: 

1  Brit.  Med.  Journ.,  1889,  vol.  ii.  p.  689. 

*  Trans.  Coll.  Phys.,  Philadelphia,  1875,  p.  183. 

8  Obst.  Trans,  for  1884.  vol.  xxvi.  p.  93. 


360  LABOR. 

"  Cum  ergo  vides  ista  signa,  tune  oportet,  ut  comprimatur  uterus  ejus  ut 
descendat  embryo  velociter."  It  was  known  to  Guillemeau,  who  says : 
"  Quelquefois  j'ai  ordoune  a  Tune  des  dites  femnies  de  presser  fort 
doucement  du  plat  de  la  main,  les  parties  superieures  du  ventre  en 
ramenant  1'enfant,  petit  &  petit,  en  bas;  telle  mediocre  compression 
facilitait  1'accouchement  en  faisant  que  les  tranchees  se  supportaient 
plus  aisement  et  facilement.1  There  are  some  curious  obstetric  customs 
among  various  nations,  which  probably  arose  from  a  recognition  of  its 
value ;  as,  for  example,  the  mode  of  delivery  adopted  among  the  Kal- 
mucks, where  the  patient  sits  at  the  foot  of  the  bed,  while  a  woman, 
seated  behind  her,  seizes  her  around  the  waist  and  squeezes  the  uterus 
during  the  pains.  Amongst  the  Japanese,  Siamese,  North  American 
Indians,  and  many  other  nations,  pressure,  applied  in  various  ways,  is 
habitually  used.[2] 

Kristeller  maintains  that  it  is  possible  to  effect  the  complete  expul- 
sion of  the  child  by  properly  applied  pressure,  even  when  the  pains  are 
entirely  absent.  Strange  as  this  may  appear  to  those  who  are  not 
familiar  with  the  effects  of  pressure,  I  believe  that,  under  exceptional 
circumstances,  when  the  pelvis  is  very  capacious,  and  the  soft  parts 
offer  but  slight  resistance,  it  can  be  done.  I  have  delivered  in  this 
way  a  patient  whose  friends  would  not  permit  me  to  apply  the  forceps, 
when  I  could  not  recognize  the  existence  of  any  uterine  contraction  at 
all,  the  foetus  being  literally  squeezed  out  of  the  uterus.  It  is  not, 
however,  as  replacing  absent  pains,  but  as  a  means  of  intensifying  and 
prolonging  the  effects  of  deficient  and  feeble  ones,  that  pressure  finds 
its  best  application. 

Its  effects  are  often  very  remarkable,  especially  in  women  of  slight 
build,  where  there  is  but  little  adipose  tissue  in  the  abdominal  walls, 
and  not  much  resistance  in  the  pelvic  tissues.  If  the  finger  be  placed 
on  the  head  wrhile  pressure  is  applied  to  the  uterus,  a  very  marked 
descent  can  readily  be  felt,  and  not  infrequently  two  or  three  applica- 
tions will  force  the  head  on  to  the  perineum.  There  are,  however, 
certain  conditions  in  which  it  is  inapplicable,  and  the  existence  of  which 
should  contra-indicate  its  use.  Thus  if  the  uterus  seem  unusually 
tender  on  pressure,  and,  a  fortiori,  if  the  tonic  contraction  of  exhaus- 
tion be  present,  it  is  inadmissible.  So  also  if  there  be  any  obstruction 
to  rapid  delivery,  either  from  narrowing  of  the  pelvis  or  rigidity  of 
the  soft  parts,  it  should  not  be  used.  The  cases  suitable  for  its  appli- 
cation are  those  in  which  the  head  or  breech  is  in  the  pelvic  cavity, 
and  the  delay  is  simply  due  to  a  want  of  sufficiently  strong  expulsive 
action. 

It  may  be  applied  in  two  ways.  The  better  plan  is  to  place  the 
patient  on  her  back  at  the  edge  of  the  bed,  and  spread  the  palms  of 
the  hands  ^  on  either  side  of  the  fundus  and  body  of  the  uterus,  and, 
when  a  pain  commences,  to  make  firm  pressure  during  its  continuance 
downward  and  backward  in  the  direction  of  the  pelvic  inlet.  As  the 
contraction  passes  off  the  pressure  is  relaxed,  and  again  resumed  when 
a  fresh  pain  begins.  In  this  way  each  pain  is  greatly  intensified,  and 


1  L'Obstetrique  aux  XVII.  et  XVIII.  Siecles.    Paris,  1892 
[*  Labor  Among  Primitive  Peoples.    Geo.  J.  Engelmann,  St.  Louis, 


1883.    8vo.  pp.  227.— ED.] 


PROLONGED    AND    PRECIPITATE    LABORS.  361 

its  effect  on  the  progress  of  the  foetus  much  increased.  It  is  not 
essential  that  the  patient  should  lie  on  her  back.  A  useful,  although 
not  so  great,  amount  of  pressure  can  be  applied  when  she  is  lying  in 
the  ordinary  obstetric  position  on  her  left  side,  the  left  hand  being 
spread  out  over  the  fundus,  leaving  the  right  free  to  watch  the  progress 
of  the  presenting  part  per  vuginam. 

Special  Value  of  Uterine  Pressure. — The  special  value  of  this 
method  of  treating  ineffective  pains  is,  that  the  amount  and  frequency 
of  the  pressure  are  completely  within  the  control  of  the  practitioner, 
and  are  capable  of  being  regulated  to  a  nicety  in  accordance  with  the 
requirements  of  each  particular  case.  It  has  the  peculiar  advantage 
of  closely  imitating  the  natural  means  of  delivery,  and  of  being  abso- 
lutely without  risk  to  the  child ;  nor  is  there  any  reason  to  think  that 
it  is  capable  of  injuring  the  mother.  At  least  I  may  safely  say  that, 
out  of  the  large  number  of  cases  in  which  I  have  used  it,  I  have  never 
seen  one  in  which  I  had  the  least  reason  to  think  that  it  had  proved 
hurtful.  Of  course,  it  is  essential  not  to  use  undue  roughness ;  firm 
and  even  strong  pressure  may  be  employed,  but  that  can  be  done 
without  being  rough,  and,  as  its  application  is  always  intermittent, 
there  is  no  time  for  it  to  inflict  any  injury  on  the  uterine  tissues. 

Pressure  is  specially  valuable  when  it  is  desirable  to  intensify 
feeble  pains.  It  may  be  serviceably  employed  when  the  pains  are 
altogether  absent,  to  imitate  and  replace  them,  provided  there  be 
nothing  but  the  absence  of  a  vis  a  tergo  to  prevent  speedy  delivery. 
In  such  cases  an  endeavor  should  be  made  to  imitate  the  pains  as 
closely  as  possible,  by  applying  the  pressure  at  intervals  of  four  or  five 
minutes,  and  entirely  relaxing  it  after  it  has  been  applied  for  a  few 
seconds. 

Instrumental  Delivery. — When  all  these  means  fail  we  have  then 
left  the  resource  of  instrumental  aid,  and  we  have  now  to  consider  the 
indications  for  the  use  of  the  forceps  under  such  circumstances.  It 
has  been  already  pointed  out  that  professional  opinion  on  this  point 
has  been  undergoing  a  marked  change ;  and  that  it  is  now  recognized 
as  an  axiom  by  the  most  experienced  teachers  that,  when  we  are  once 
convinced  that  the  natural  efforts  are  failing,  and  are  unlikely  to  effect 
delivery,  except  at  the  cost  of  long  delay,  it  is  far  better  to  interfere 
soon  rather  than  late,  and  thus  prevent  the  occurrence  of  the  serious 
symptoms  accompanying  protracted  labor.  The  recent  important 
debate  on  the  use  of  the  forceps  at  the  Obstetrical  Society  of  London 
remarkably  illustrated  these  statements,  for  while  there  was  much 
difference  of  opinion  as  to .  the  advisability  of  applying  the  forceps 
when  the  head  was  high  in  the  pelvis,  a  class  of  cases  not  now  under 
consideration,  it  was  very  generally  admitted  that  the  modern  teaching 
was  based  on  correct  scientific  grounds.  This  is,  of  course,  directly 
opposed  to  the  view  so  long  taught  in  our  standard  works,  in  which 
instrumental  interference  was  strictly  prohibited  unless  all  hope  of 
natural  delivery  was  at  an  end  ;  and  in  which  the  commencement  at 
least,  if  not  the  complete  establishment,  of  symptoms  of  exhaustion, 
was  considered  to  be  the  only  justification  for  the  application  of  the 
forceps  in  lingering  labor. 


362  LABOR. 

The  reasons  which  led  the  late  distinguished  master  of  the  Rotunda 
Hospital  to  a  more  frequent  use  of  the  forceps  are  so  well  expressed  in 
his  report  for  1872,  that  I  venture  to  quote  them,  as  the  best  justifica- 
tion for  a  practice  that  many  practitioners  of  the  older  school  will,  no 
doubt,  be  inclined  to  condemn  as  rash  and  hazardous.  He  says  :  l  "  Our 
established  rule  is  that  so  long  as  Nature  is  able  to  eifect  its  purpose 
without  prejudice  to  the  constitution  of  the  patient,  danger  to  the  soft 
parts,  or  the  life  of  the  child,  we  are  in  duty  bound  to  allow  the  labor 
to  proceed  ;  but  as  soon  as  we  find  the  natural  efforts  are  beginning  to 
fail,  and  after  having  tried  the  milder  means  for  relaxing  the  parts  or 
stimulating  the  uterus  to  increased  action,  and  the  desired  effects  not 
being  produced,  we  consider  we  are  in  duty  bound  to  adopt  still 
prompter  measures,  and  by  our  timely  assistance  relieve  the  sufferer 
from  her  distress  and  her  offspring  from  an  imminent  death.  Why, 
may  I  ask,  should  we  permit  a  fellow-creature  to  undergo  hours  of 
torture  when  we  have  the  means  of  relieving  her  within  our  reach  ? 
Why  should  she  be  allowed  to  waste  her  strength,  and  incur  the  risks 
consequent  upon  long  pressure  of  the  head  on  the  soft  parts,  the  ten- 
dency to  inflammation  and  sloughing,  or  the  danger  of  rupture,  not  to 
speak  of  the  poisonous  miasma  which  emanates  from  an  inflammatory 
state  of  the  passages,  the  result  of  tedious  labor,  and  which  is  one  of 
the  fertile  causes  of  puerperal  fever  and  all  its  direful  effects,  attributed 
by  some  to  the  influence  of  being  confined  in  a  large  maternity,  and 
not  to  its  proper  source,  i.  e.,  the  labor  being  allowed  to  continue  till 
inflammatory  symptoms  appear  ?  The  more  we  consider  the  benefits 
of  timely  interference,  and  the  good  results  which  follow  it,  the  more 
are  we  induced  to  pursue  the  system  we  have  adopted,  and  to  inculcate 
to  those  we  are  instructing  the  advantages  to  be  gained  by  such  practice, 
both  in  saving  the  life  of  the  child  as  well  as  securing  the  greater  safety 
of  the  mother."  It  would  be  impossible  to  put  the  matter  in  a  stronger 
or  clearer  light,  and  I  feel  confident  that  these  views  will  be  indorsed 
by  all  who  have  adopted  the  more  modern  practice. 

Effect  of  Early  Interference  on  the  Infantile  Mortality.  —  In  the 
first  edition  of  this  work  I  used  the  statistics  of  Dr.  Hamilton,  of 
Falkirk,  and  other  modern  writers,  as  proving  that  a  more  frequent 
use  of  the  forceps  than  had  been  customary  diminished  in  a  remarkable 
degree  the  infantile  mortality.  Dr.  Galabin2  has  recently  published  an 
admirable  paper  on  this  subject,  in  which,  by  a  careful  criticism  of 
these  figures,  he  has,  I  think,  proved  that  the  conclusions  drawn  from 
them  are  open  to  doubt,  and  that  the  saving  of  infantile  life  following 
more  frequent  forceps  delivery  is  by  no  means  so  great  as  I  had  sup- 
posed. Dr.  Roper,  in  his  remarks  in  the  recent  debate  in  the  Obstet- 
rical Society,  brought  forward  some  strong  arguments  in  support  of 
the  same  view.  This,  however,  does  not  in  any  way  touch  the  main 
points  at  issue  referred  to  in  the  preceding  paragraph. 

Possible  Dangers  attending  the  Use  of  the  Forceps.  —  It  is,  of 
course,  right  that  we  should  consider  the  opposite  point  of  view,  and 
reflect  on  the  disadvantages  which  may  attend  the  interference  advo- 


»  Obst1?  ^""^IJwr-™*  Ofithe  Rotunda  Lying-in  Hospital,  Dublin,  for  the  year  ending  1872. 


PROLONGED    AND    PRECIPITATE    LABORS.  363 

cated.  Here  I  should  point  out  that  I  am  now  writing  only  of  the  use 
of  the  forceps  in  simple  inertia,  when  the  head  is  low  in  the  pelvic 
cavity,  and  when  all  that  is  wanted  is  a  slight  vis  a  f route,  to  supplement 
the  deficient  vis  a  twgo.  The  use  of  the  instrument  when  the  head  is 
arrested  high  in  the  pelvis,  or  in  cases  of  deformity,  or  before  the  os 
uteri  is  completely  expanded,  is  an  entirely  different  and  much  more 
serious  matter,  and  does  not  enter  into  the  present  discussion.  The 
chief  question  to  decide  is,  if  there  be  sufficient  risk  to  the  mother  to 
counterbalance  that  of  delay.  It  will,  of  course,  be  conceded  by  all 
that  the  forceps  in  the  hands  of  a  coarse,  bungling,  and  ignorant  prac- 
titioner, who  has  not  studied  the  proper  mode  of  operating,  may  easily 
inflict  serious  damage.  The  possibility  of  inflicting  injury  in  this  way 
should  act  as  a  warning  to  every  obstetrician  to  make  himself  thor- 
oughly acquainted  with  the  proper  mode  of  using  the  instrument,  and 
to  acquire  the  manual  skill  which  practice  and  the  study  of  the 
mechanism  of  delivery  will  alone  give ;  but  it  can  hardly  be  used  as 
an  argument  against  its  use.  If  that  were  admitted,  surgical  inter- 
ference of  any  kind  would  be  tabooed,  since  there  is  none  that  ignorance 
and  incapacity  might  not  render  dangerous. 

Assuming,  therefore,  that  the  practitioner  is  able  to  apply  the  forceps 
skilfully,  is  there  any  inherent  danger  in  its  use  ?  I  think  all  who 
dispassionately  consider  the  question  must  admit  that,  in  the  class  of 
cases  alluded  to,  the  operation  is  so  simple  that  its  disadvantages  can- 
not for  a  moment  be  weighed  against  those  attending  protraction  and 
its  consequences.  Against  this  conclusion  statistics  may  possibly  be 
quoted,  such  as  those  of  Churchill,  who  estimated  that  one  in  twenty 
mothers  delivered  by  forceps  in  British  practice  was  lost.f1]  But 
the  fallacy  of  such  figures  is  apparent  on  the  slightest  consideration ; 
and  by  no  one  has  this  been  more  conclusively  shown  than  by  Drs. 
Hicks  and  Phillips  in  their  paper  on  tables  of  mortality  after  obstetric 
operations,2  where  it  is  proved  in  the  clearest  manner  that  such  results 
are  due  not  to  the  treatment,  but  rather  to  the  fact  that  the  treatment 
was  so  long  delayed. 

It  is  quite  impossible  to  lay  down  any  precise  rule  as  to  when  the 
forceps  should  be  used  in  uterine  inertia.  Each  case  must  be  treated 
on  its  own  merits,  and  after  a  careful  estimate  of  the  effects  of  the 
pains.  The  rules  generally  taught  were  that  the  head  should  be 
allowed  to  rest  at  or  near  the  perineum  for  a  number  of  hours,  and 
that  interference  was  contra-indicated  if  the  slightest  progress  were 
being  made.  It  is  needless  to  say  that  both  of  these  rules  are  incom- 
patible with  the  views  I  have  been  inculcating,  and  that  any  rule 
based  upon  the  length  of  time  the  second  stage  of  labor  has  lasted 
must  necessarily  be  misleading.  What  has  to  be  done,  I  conceive,  is 
to  watch  the  progress  of  the  case  anxiously  after  the  second  stage  has 
fairly  commenced,  and  to  be  guided  by  an  estimate  of  the  advance  that 
is  being  made  and  the  character  of  the  pains,  bearing  in  mind  that  the 
risk  to  the  mother,  and  still  more  to  the  child,  increases  seriously  with 

P  Churchill's  statistics  were  collected  in  so  unreliable  a  way,  that  I  have  long  since  ceased  to 
put  any  faith  in  them. — ED.] 
a  Obst.  Trans.,  1872,  vol.  xiii.  p.  55. 


364  LABOR. 

each  hour  that  elapses.  If  we  find  the  progress  slow  and  unsatisfac- 
tory, the  pains  flagging  and  insufficient,  and  incapable  of  being 
intensified  by  the  means  indicated,  then,  provided  the  head  be  low  in 
the  pelvis,  it  is  better  to  assist  at  once  by  the  forceps,  rather  than  to 
wait  until  we  are  driven  to  do  so  by  the  state  of  the  patient.1 

1  It  may,  perhaps,  be  of  interest  in  connection  with  this  important  topic  in  practical  midwifery 
if  I  reprint  a  letter  I  published  some  years  ago  in  the  Medical  Times  and  Gazette.  An  historical 
case,  such  as  that  of  which  it  treats,  will  better  illustrate  the  evil  effects  that  may  follow  un- 
necessary delay  than  any  amount  of  argument.  It  seems  to  me  impossible  to  read  the  details  of 
the  delivery  it  describes  without  being  forcibly  struck  with  the  disastrous  results  which  followed 
the  practice  adopted,  which,  however,  was  strictly  in  accordance  with  that  considered  correct, 
up  to  a  quite  recent  date,  by  the  highest  obstetric  authorities. 

ON  THE  DEATH  OF  THE  PRINCESS  CHARLOTTE  OF  WALES. 
(To  the  Editor  of  the  Medical  Times  and  Gazette.) 

SIR:  The  letter  of  your  correspondent,  "An  Old  Accoucheur,"  regarding  the  death  of  the 
Princess  Charlotte,  raises  a  question  of  great  interest— viz.,  whether  the  fatal  result  might  have 
been  averted  under  other  treatment?  The  history  of  the  case  is  most  instructive,  and  I  think  a 
careful  consideration  of  it  leaves  little  room  to  doubt  that,  though  the  management  of  the  labor 
was  quite  in  accordance  with  the  teaching  of  the  day,  it  was  entirely  opposed  to  that  of  modern 
obstetric  science.  The  following  account  of  the  labor  may  interest  your  readers,  and  will  probably 
be  new  to  most  of  them.  It  is  contained  in  a  letter  from  Dr.  John,  Sims  to  the  late  Dr.  Joseph 
Clarke,  of  Dublin : 

"  LONDON,  November  15, 1817. 

"  MY  DEAR  SIR  :  I  do  not  wonder  at  your  wishing  to  have  a  direct  statement  of  the  labor  of  her 
Royal  Highness  the  Princess  CnarJotte',  the  fatal  issue  of  which  has  involved  the  whole  nation  in 
distress.  You  must  excuse  my  being  very  concise,  as  I  have  been,  and  am.  very  much  hurried. 
I  take  the  opportunity  of  writing  this  in  a  lying-in  chamber.  Her  Royal  Highness's  labor  com- 
menced by  the  discharge  of  the  liquor  amnii  about  seven  o'clock  on  Monday  evening,  and  the 
pains  followed  soon  after.  They  continued  through  the  night  and  a  greater  part  of  the  next  day — 
sharp,  soft,  but  very  ineffectual.  Toward  the  evening  Sir  Richard  Croft  began  to  suspect  that 
labor  might  not  terminate  without  artificial  assistance,  and  a  message  was  despatched  for  me. 
I  arrived  at  two  on  Wednesday  morning.  The  labor  was  now  advancing  more  favorably,  and 
both  Dr.  Baillie  and  myself  concurred  in  the  opinion  that  it  would  not  be  advisable  to  inform  her 
Royal  Highness  of  my  arrival.  From  this  time  to  the  end  of  her  labor  the  progress  was  uniform, 
though  very  slow,  the  patient  in  good  spirits,  the  pulse  calm,  and  there  never  was  room  to  enter- 
tain a  question  about  the  use  of  instruments.  About  six  in  the  afternoon  the  discharge  became 
of  a  green  color,  which  led  to  a  suspicion  that  the  child  might  be  dead;  still  the  giving  assistance 
was  quite  out  of  the  question,  as  the  pains  now  became  more  effectual,  and  the  labor  proceeded 
regularly,  though  slowly.  The  child  was  born  without  artificial  assistance  at  nine  o'clock  in  the 
evening.  Attempts  were  made  for  a  good  while  to  reanimate  it  by  inflating  the  lungs,  friction, 
hot  baths,  etc.,  but  without  effect;  the  heart  could  not  be  made  to  beat  even  once.  Soon  after 
delivery.  Sir  Richard  Croft  discovered  that  the  uterus  was  contracted  in  the  middle  in  the  hour- 
glass form,  and  as  some  hemorrhage  commenced  it  was  agreed  that  the  placenta  should  be 
brought  away  by  introducing  the  hand.  This  was  done  about  half  an  hour  after  the  delivery  of 
the  child,  with  more  ease  and  less  blood  than  usual.  Her  Royal  Highness  continued  well' for 
about  two  hours;  she  then  complained  of  being  sick  at  stomach,  and  of  noise  in  the  ears,  began 
to  be  talkative,  and  her  pulse  became  frequent ;  but  I  understand  she  was  very  quiet  after  this, 
and  her  pulse  calm.  About  half-past  twelve  o'clock  she  compiaiued  of  severe  pain  In  the  chest, 
became  extremely  restless,  with  rapid,  weak,  and  irregular  pulse.  At  this  time  I  saw  her  for  the 
first  time.  It  has  been  said  that  we  had  all  gone  to  bed,  but  that  is  not  a  fact ;  Croft  did  not  leave 
her  room,  Baillie  retired  about  eleven,  and  I  went  to  my  bedchamber  and  laid  down  in  my  clothes 
at  twelve.  By  dissection,  some  bloody  fluid  (two  ounces)  was  found  in  the  pericardium,  supposed 
to  be  thrown  out  in  articulo  mortis.  The  brain  and  other  organs  all  sound,  except  the  right 
ovarium,  which  was  distended  into  a  cyst  the  size  of  a  hen's  egg.  The  hour-glass  contraction  of 
the  uterus  still  visible,  and  a  considerable  quantity  of  blood  in  the  cavity  of  the  uterus— but  those 
present  dispute  about  the  quantity,  so  much  as  from  twelve  ounces  to  a  pound  and  a  half— her 
uterus  extending  as  high  as  her  navel.  The  cause  of  her  Royal  Highness's  death  is  certainly 
somewhat  obscure ;  the  symptoms  were  such  as  attend  death  from  hemorrhage,  but  the  loss  of 
blood  did  not  seem  to  be  sufficient  to  account  for  a  fatal  issue.  It  is  possible  that  the  effusion 
into  the  pericardium  took  place  earlier  than  was  supposed,  and  it  does  not  seem  to  be  quite  cer- 
tain that  this  might  not  be  the  cause.  That  I  did  not  see  her  Royal  Highness  more  early  was  awk- 
ward, and  it  would  have  been  better  that  I  had  been  introduced  before  the  labor  was  expected  ; 
and  it  should  have  been  understood  that  when  labor  came  on  I  should  be  sent  to  without  waiting 
to  know  whether  a  consultation  was  necessary  or  not.  I  thought  so  at  the  time,  but  I  could  not 
propose  such  an  arrangement  to  Croft.  But  this  is  entirely  entre  nous.  I  am  glad  to  hear  that 
your  son  is  well,  and  with  all  my  family,  wish  to  be  remembered  to  him.  We  were  happy  to 
hear  that  he  was  agreeably  married. 

"I  remain,  my  dear  Doctor, 

"Ever  yours  most  truly, 

"  JOHN  SIMS,  M.D. 

"  This  letter  is  confidential,  as  perhaps  I  might  be  blamed  for  writing  any  particulars  without 
the  permission  of  Prince  Leopold." 

What  are  the  facts  here  shown?  Here  was  a  delicate  young  woman,  prepared  for  the  trial  before 
her,  as  Baron  Stockmar  tells  us,  by  "  lowering  the  organic  strength  of  the  mother  by  bleeding, 
aperients,  and  low  diet,"  who  was  allowed  to  go  on  in  lingering  feeble  labor  for  no  less  than  fifty 
hours  after  the  escape  of  the  liquor  amnii !  Such  was  the  groundless  dread  of  instrumental  inter- 
ference then  prevalent  that,  although  the  case  dragged  on  its  weary  length  with  feeble,  ineffectual 
pains,  every  now  and  then  increasing  in  intensity'and  then  falling  off  again,  it  is  stated  "  there 


PROLONGED    AND    PRECIPITATE    LABORS.  365 

Precipitate  Labor  Less  Common  than  Lingering.  —  Undue 
rapidity  of  labor  is  certainly  more  uncommon  than  its  converse,  but 
still  it  is  by  no  means  of  unfrequent  occurrence.  Most  obstetric 
works  contain  a  formidable  catalogue  of  evils  that  may  attend  it,  such 
as  rupture  of  the  cervix,  or  even  of  the  uterus  itself,  from  violence  of  the 
uterine  action ;  laceration  of  the  perineum  from  the  presenting  part 
being  driven  through  before  dilatation  has  occurred ;  fainting  from 
the  sudden  emptying  of  the  uterus ;  hemorrhage  from  the  same  cause. 
With  regard  to  the  child  it  is  held  that  the  pressure  to  which  it  is 
subjected,  and  sudden  expulsion  while  the  mother  is  in  the  erect  posi- 
tion, may  prove  injurious.  Without  denying  that  these  results  may 
possibly  occur  noAV  and  again,  in  the  majority  of  cases  over-rapid 
labor  is  not  attended  with  any  evil  effects. 

[As  an  instance  of  rapid  delivery,  I  report  the  following  case :  In 
September,  1848,  a  Ill-para  of  twenty-seven,  in  Philadelphia,  was 
awakened  in  the  night  by  a  violent  uterine  pain,  followed  at  once  by 
a  sensation  of  approaching  delivery.  Her  husband,  a  noted  accoucheur, 
was  only  up  in  time  to  receive  the  foetus,  which  came  by  the  same  pain 
that  awakened  his  wife.  A  second  fcetus  (both  females)  soon  followed, 
and  the  whole  labor,  in  all  its  stages,  occupied  but  forty-five  minutes. 
In  two  prior  and  two  subsequent  labors  there  was  no  marked  haste  in 
uterine  action.  The  mother,  who  is  living  at  seventy-two,  has  never 
been  a  strong  woman. — ED.] 

Precipitate  labor  may  generally  be  traced  to  one  of  two  conditions, 
or  to  a  combination  of  both ;  excessive  force  and  rapidity  of  the  pains, 
or  unusual  laxity  and  Avant  of  resistance  of  the  soft  parts.  The  pre- 
cise causes  inducing  these  it  is  difficult  to  estimate.  In  some  cases  the 
former  may  depend  on  an  undue  amount  of  nervous  excitability,  and 
the  latter  on  the  constitutional  state  of  the  patient  tending  to  relaxa- 
tion of  the  tissues. 

Whatever  the  cause,  the  extreme  rapidity  of  labor  is  occasionally 
remarkable,  and  one  strong  pain  may  be  sufficient  to  effect  the  expul- 

never  was  room  to  entertain  a  question  about  the  use  of  instruments  "  ;  and  even  "  when  the  dis- 
charge became  of  a  green  color still  the  giving  assistance  was  quite  out  of  the  question  "  ! 

Can  any  reasonable  man  doubt  that  if -the  forceps  had  been  employed  hours  and  hours  before — 
say  on  Tuesday,  when  the  pains  fell  off— the  result  would  probably  have  been  very  different,  and 
that  the  life  of  the  child,  destroyed  by  the  enormously  prolonged  second  stage,  would  have  been 
saved?  It  must  be  remembered  that  early  on  Tuesday  morning  delivery  was  expected,  so  that 
the  head  must  then  have  been  low  in  the  pelvis  (vide  Stockmar's  Memoirs,  vol.  i.  p.  63).  It  would 
be  difficult  to  find  a  case  which  more  forcibly  illustrates  the  danger  of  delay  in  the  second  stage 
of  labor.  Then  what  follows?  The  uterus,  exhausted  by  the  lengthy  efforts  it  should  have  been 
spared,  fails  to  contract  effectually ;  nor  do  we  hear  of  any  attempts  to  produce  contraction  by 
pressure.  The  relaxed  organ  becomes  full  of  clots,  extending  up  to  the  umbilicus,  and  all  the 
most  characteristic  symptoms  ot  concealed  post-partum  hemorrhage  develop  themselves.  She 
complained  "of  being  sick  at  stomach,  and  of  noise  in  her  ears,  began  to  be  talkative,  and  her 
pulse  became  frequent."  Before  long  other  symptoms  came  on,  graphically  described  by  Baron 
Stockraar,  and  which  seem  to  point  to  the  formation  of  a  clot  in  the  heart  and  pulmonary  arte- 
ries—a most  likely  occurrence  after  such  a  history.  "  Baillie  sent  me  word  that  he  wished  me  to 
see  the  Princess.  I  hesitated,  but  at  last  went  with  him.  She  was  suffering  from  spasms  of  the 
chest  arid  difficulty  of  breathing,  in  great  pain,  and  very  restless,  and  threw  herself  continually 
from  one  side  of  the  bed  to  the  other,  speaking  now  to  Baillie,  now  to  Croft.  Baillie  said  to  her, 
'  Here  comes  an  old  friend  of  yours.'  She  held  out  her  left  hand  to  me,  hastily,  and  pressed  mine 
warmly  twice.  I  felt  her  pulse ;  it  was  going  very  fast— the  beats  now  strong,  now  feeble,  now 
intermittent." 

Here  was  evidently  something  different  from  the  exhaustion  of  hemorrhage  :  and  no  one  who 
has  witnessed  a  case  of  pulmonary  obstruction  can  fail  to  recognize  in  this  account  an  accurate 
delineation  of  its  dreadful  symptoms.  Surely  this  lamentable  story  can  only  lead  to  the  conclu- 
sion that  the  unhappy  and  gifted  Princess  fell  a  victim  to  the  dread  of  that  bugbear,  "  meddle- 
some midwifery,"  which  has  so  long  retarded  the  progress  of  obstetrics. 

I  am,  etc.,        W.  S.  PLAYFAIE. 

CURZON  STREET,  MAYFAIK,  \V.,  November  29,  1872. 


366  LABOR. 

sion  of  the  child  with  little  or  no  preliminary  warning.  I  have  known 
a  child  to  be  expelled  into  the  pan  of  a  water-closet,  the  only  previous 
indication  of  commencing  labor  being  a  slight  griping  pain,  which  led 
the  mother  to  fancy  that  an  action  of  the  bowels  was  about  to  take 
place.  More  often  there  is  what  may  be  described  as  a  storm  of  uterine 
contractions,  one  pain  following  the  other  with  great  intensity,  until 
the  foetus  is  expelled.  The  natural  effect  of  this  is  to  produce  a  great 
amount  of  alarm  or  nervous  excitement,  which  of  itself  forms  one  of 
the  worst  results  of  this  class  of  labor.  It  is  under  such  circumstances 
that  temporary  mania  occurs,  produced  by  the  intensity  of  the  suffering, 
under  which  the  patient  may  commit  acts,  her  responsibility  for  which 
may  fairly  be  open  to  question. 

Little  Treatment  Possible. — Little  can  be  done  in  treating  undue 
rapidity  of  labor.  We  can,  to  some  extent,  modify  the  intensity  of  the 
pains  by  urging  the  patient  to  refrain  from  voluntary  efforts,  and  to 
open  the  glottis  by  crying  out,  so  that  the  chest  may  no  longer  be  a 
fixed  point  for  muscular  action.  Opiates  have  been  advised  to  control 
uterine  action,  but  it  is  needless  to  point  out  that,  in  most  cases,  there 
is  no  time  for  them  to  take  effect.  Chloroform  will  often  be  found 
most  valuable,  from  the  rapidity  with  which  it  can  be  exhibited ;  and 
its  power  of  diminishing  uterine  action,  which  forms  one  of  its  chief 
drawbacks  in  ordinary  practice,  will  here  prove  of  much  service. 


CHAPTER   X. 

LABOR  OBSTRUCTED  BY  FAULTY  CONDITION  OF   THE 
SOFT  PARTS. 

Rigidity  of  the  Cervix  a  Frequent  Cause  of  Protracted  Labor. 
— One  of  the  most  frequent  causes  of  delay  in  the  first  stage  of  labor 
is  rigidity  of  the  cervix  uteri,  which  may  depend  on  a  variety  of  con- 
ditions. It  is  often  produced  by  premature  escape  of  the  liquor  amnii, 
in  consequence  of  which  the  fluid  wedge,  which  is  Nature's  means  of 
dilating  the  os,  is  destroyed,  and  the  hard  presenting  part  is  conse- 
quently brought  to  bear  directly  upon  the  tissues  of  the  cervix,  which 
are  thus  unduly  irritated,  and  thrown  into  a  state  of  spasmodic  con- 
traction. At  other  times  it  may  be  due  to  constitutional  peculiarities, 
among  which  there  is  none  so  common  as  a  highly  nervous  and  emo- 
tional temperament,  which  renders  the  patient  peculiarly  sensitive  to 
her  sufferings,  and  interferes  with  the  harmonious  action  of  the  uterine 
fibres.  The  pains,  in  such  cases,  cause  intense  agony,  are  short  and 
cramp-like  in  character,  but  have  little  or  no  effect  in  producing  dila- 
tation ;  the  os  often  remaining  for  many  hours  without  any  appreciable 
alteration,  its  edges  being  thin  and  tightly  stretched  over  the  head. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.       367 

Less  often,  and  this  is  generally  met  with  in  stout,  plethoric  women, 
the  edges  of  the  os  are  thick  and  tough. 

The  effects  of  prolongation  of  labor  from  this  cause  will  vary  much 
under  different  circumstances.  If  the  liquor  amnii  be  prematurely 
evacuated,  the  presenting  part  presses  directly  upon  the  cervix,  and 
the  case  is  then  practically  the  same  as  if  the  labor  was  in  the  second 
stage.  Hence  grave  symptoms  may  soon  develop  themselves,  and 
early  interference  may  be  imperatively  demanded.  If  the  membranes 
be  unruptured,  delay  will  be  of  comparatively  little  moment,  and  con- 
siderable time  may  elapse  without  serious  detriment  to  either  the 
mother  or  child. 

The  treatment  will  naturally  vary  much  with  the  cause  and  the 
state  of  the  patient.  In  the  majority  of  cases,  especially  if  the  mem- 
branes be  intact,  patience  and  time  are  sufficient  to  overcome  the  ob- 
stacle ;  but  it  is  often  in  the  power  of  the  accoucheur  materially  to  aid 
dilatation  by  appropriate  management.  Sometimes  Nature  overcomes 
the  obstruction  by  lacerating  the  opposing  structures ;  and  cases  are  on 
record  in  which  even  a  complete  ring  of  the  cervix  has  been  torn  off 
and  come  away  before  the  head. 

Many  remedies  have  been  recommended  for  facilitating  dilatation, 
some  of  wrhich  no  doubt  act  beneficially.  Among  those  most  fre- 
quently resorted  to  was  venesection,  and  with  it  was  generally  asso- 
ciated the  administration  of  nauseating  doses  of  tartar  emetic.  Both 
these  acted  by  producing  temporary  depression,  under  which  the 
resistance  of  the  soft  parts  was  lessened.  They  probably  answer  best 
in  cases  in  which  there  was  a  rigid  and  tough  cervix ;  and  they  might 
prove  serviceable,  even  yet,  in  stout,  plethoric  women  of  robust  frame. 
Practically  they  are  now  seldom,  if  ever,  employed,  and  other  and  less 
debilitating  remedies  are  preferred.  The  agent,  par  excellence,  most 
serviceable  is  chloral,  which  is  of  special  value  in  the  more  common 
cases  in  which  rigidity  is  associated  with  spasmodic  contraction  of  the 
muscular  fibres  of  the  cervix.  Two  or  three  doses  of  fifteen  grains, 
repeated  at  intervals  of  twenty  minutes,  are  often  of  almost  magical 
efficacy,  the  pains  becoming  steady  and  regular,  and  the  os  gradually 
relaxing  sufficiently  to  allow  the  passage  of  the  head.  Should  the 
chloral  be  rejected  by  the  stomach,  it  may  be  satisfactorily  adminis- 
tered per  rectum.  Chloroform  acts  much  in  the  same  way,  but  on  the 
whole  less  satisfactorily,  its  effects  being  often  too  great ;  while  the 
peculiar  value  of  chloral  is  its  influence  in  promoting  relaxation  of  the 
tissues,  without  interfering  with  the  strength  of  the  pains. 

Various  local  means  of  treatment  may  be  also  advantageously  used. 
One  is*  the  warm  bath,  which  is  much  used  in  France.  It  is  of  un- 
questionable value  where  there  is  mere  rigidity,  and  may  be  used  either 
as  an  entire  bath,  or  as  a  hip-bath,  in  which  the  patient  sits  from 
twenty  minutes  to  half  an  hour.  The  objection  is  the  fuss  and  excite- 
ment it  causes,  and,  for  this  reason,  it  is  an  expedient  seldom  resorted 
to  in  this  country.  A  similar  effect  is  produced,  and  much  more  easily, 
by  a  douche  of  tepid  water  upon  the  cervix.  This  can  be  very  easily 
administered,  the  pipe  of  a  Higginson's  syringe  being  guided  up  to  the 
cervix  by  the  index  finger  of  the  right  hand,  and  a  stream  of  water 


368  LABOR. 

projected  against  it  for  five  or  ten  minutes.  Smearing  the  os  with 
extract  of  belladonna  is  advised  by  Continental  authorities,  but  its 
effects  are  more  than  doubtful.  Horton  l  advocates  the  injection  into 
the  tissue  of  the  cervix  of  fa  of  a  grain  of  atropine  by  means  of  a  hypo- 
dermatic syringe,  and  speaks  very  favorably  of  the  practice. 

Artificial  Dilatation. — Artificial  dilatation  of  the  cervix  by  the 
finger  has  often  been  recommended,  and  has  been  the  subject  of  much 
discussion,  especially  in  the  Edinburgh  school,  where  it  was  formerly 
commonly  employed.  It  is  capable  of  being  very  useful,  but  it  may 
also  do  much  injury  when  roughly  and  injudiciously  used.  The  class 
of  cases  in  which  it  is  most  serviceable  are  those  in  which  the  liquor 
amnii  has  been  long  evacuated,  and  in  which  the  head,  covered  by  the 
tightly  stretched  cervix,  has  descended  low  into  the  pelvic  cavity. 
Under  these  circumstances,  if  the  finger  be  passed  gently  within  the  os 
during  a  pain,  and  its  margin  pressed  upward  and  over  the  head,  as  it 
were,  while  the  contraction  lasts,  the  progress  of  the  case  may  be  mate- 
rially facilitated.  This  manoeuvre  is  somewhat  similar  to  that  which 
has  been  already  spoken  of,  when  the  anterior  lip  of  the  cervix  is 
caught  between  the  head  and  the  pubic  bone,  and,  if  properly  per- 
formed, I  believe  it  to  be  quite  safe,  and  often  of  great  value.  It  is 
not,  however,  well  adapted  for  those  cases  in  which  the  membranes 
are  still  intact,  or  in  which  the  os  remains  undilated  when  the  head  is 
still  high  in  the  pelvis.  When  there  is  much  delay  under  these  con- 
ditions, and  interference  of  some  kind  seems  called  for,  the  dilatation 
may  be  much  assisted  by  the  use  of  caoutchouc  dilators,  described  in 
the  chapter  on  the  induction  of  premature  labor,  which  imitate  Nature's 
method  of  opening  up  the  os,  and  also  act  as  a  direct  stimulant  to 
uterine  contraction.  But  it  should  be  remembered  that  it  is  precisely 
in  such  cases  that  delay  is  least  prejudicial.  If,  however,  the  os  be 
excessively  long  in  opening,  its  dilatation  may  be  safely  and  efficiently 
promoted  by  passing  within  it,  and  distending  with  water,  one  of  the 
smallest-sized  bags ;  and,  after  this  has  been  in  position  from  ten  to 
twenty  minutes,  it  may  be  removed,  and  a  larger  one  substituted. 

Rigidity  depending-  upon  Organic  Causes. —  Every  now  and 
again  we  meet  with  cases  in  which  the  obstacle  depends  upon  organic 
changes  in  the  cervix,  the  most  common  of  which  are  cicatricial  hard- 
ening from  former  lacerations ;  hypertrophic  elongation  of  the  cervix 
from  disease  antecedent  to  pregnancy ;  or  even  agglutination  and 
closure  of  the  os  uteri.  Cicatrices  are  generally  the  result  of  lacerations 
during  former  labors.  They  implicate  a  portion  only  of  the  cervix, 
which  they  render  hard,  rigid,  and  undilatable,  while  the  remainder 
has  its  natural  softness.  They  can  readily  be  made  out  by  the-  exam- 
ining finger.  A  somewhat  similar,  but  much  more  formidable,  obstruc- 
tion is  occasionally  met  with  in  cases  of  old-standing  hypertrophic 
elongation  of  the  cervix,  which  is  generally  associated  with  prolapse. 
In  most  cases  of  this  kind  the  cervix  becomes  softened  during  preg- 
nancy, so  that  dilatation  occurs  without  any  unusual  difficulty.  But 
this  does  not  always  happen.  A  good  example  is  related  by  Mr. 

i  Amer.  Journ.  of  Obstet,  1878,  vol.  xi.  p.  482. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.      369 

Roper,  in  the  seventh  volume  of  the  Obstetrical  Transactions  (p.  233), 
in  which  such  a  cervix  formed  an  almost  insuperable  obstacle  to  the 
passage  of  the  child. 

Carcinoma  of  the  cervix  uteri,  which  produces  extensive  thickening 
and  induration  of  its  tissues,  and  even  advanced  malignant  disease  of 
the  uterus,  is  no  bar  to  conception.  The  relations  of  malignant  disease 
to  pregnancy  and  parturition  have  recently  been  well  studied  by  Dr. 
Herman.1  He  concludes  that  cancer  renders  the  patient  inapt  to  con- 
ceive, but  that  when  pregnancy  does  occur  there  is  a  tendency  to  the 
intra-uterine  death  and  premature  expulsion  of  the  foetus,  and  the 
growth  of  the  cancer  is  accelerated.  When  delivery  is  accomplished 
naturally  there  is  generally  expansion  of  the  cervix  by  fissuring  of  its 
tissue,  but  the  harder  forms  of  cancer  may  form  an  insuperable  obstacle 
to  delivery. 

Agglutination  of  the  margins  of  the  os  uteri  is  occasionally  met 
with,  and  must,  of  course,  have  occurred  after  conception.  It  is 
generally  the  result  of  some  inflammatory  affection  of  the  cervix  during 
the  early  mouths  of  gestation  ;  and  I  have  known  it  recur  in  the  same 
woman  in  two  successive  pregnancies.  Usually  it  is  not  associated 
with  any  hardness  or  rigidity,  but  the  entire  cervix  is  stretched  over 
the  presenting  part,  and  forms  a  smooth  covering,  in  which  the  os  may 
only  exist  as  a  small  dimple,  and  may  be  very  difficult  to  detect  at  all. 
Occlusion  of  the  os  uteri  from  inflammatory  change  sometimes  so 
alters  the  cervix  that  no  sign  of  the  original  opening  can  be  dis- 
covered ;  and  in  two  such  instances  the  Caesarean  operation  has  been 
performed  in  the  United  States,  by  which  the  women  were  saved.2 

Their  Treatment. — Any  of  these  mechanical  causes  of  rigidity  may 
at  first  be  treated  in  the  same  way  as  the  more  simple  cases ;  and  with 
patience,  the  use  of  chloral  and  chloroform,  and  of  the  fluid  dilators, 
sufficient  expansion  to  permit  the  passage  of  the  head  will  often  take 
place.  But  if  these  methods  produce  no  effect,  and  symptoms  of  con- 
stitutional irritation  are  beginning  to  develop  themselves,  other  and 
more  radical  means  of  overcoming  the  obstruction  may  be  required. 

Under  such  circumstances  incision  of  the  cervix  may  be  not  only 
justifiable  but  essential,  and  it  frequently  answers  extremely  well.  On 
the  Continent  it  is  resorted  to  much  more  frequently  and  earlier  than 
in  this  country,  and  with  the  most  beneficial  results.  The  operation 
offers  no  difficulties.  The  simplest  way  of  performing  it  is  to  guard 
the  greater  portion  of  the  blade  of  a  straight  blunt-pointed  bistoury  by 
wrapping  lint  or  adhesive  plaster  around  it,  leaving  about  half  an  inch 
of  cutting  edge  toward  its  point.  This  is  guided  to  the  cervix,  on  the 
under  surface  of  the  index  finger,  and  three  or  four  notches  are  cut  in 
the  circumference  of  the  os  to  about  the  depth  of  a  quarter  of  an  inch. 
Very  generally,  especially  when  the  obstruction  is  only  due  to  old 
cicatrices,  the  pains  will  now  speedily  Affect  complete  expansion,  which 
may  be  very  advantageously  aided  by  applying  the  hydrostatic  dilators. 
When  the  obstruction  is  due  to  carcinomatous  infiltration  or  inflam- 
matory thickening,  the  case  is  much  more  complicated,  and  will  pain- 

1  Obst.  Trans,  for  1878,  vol.  xx.  p.  191. 

4  Harris's  note  to  second  American  edition. 

24 


LABOR. . 

fully  tax  the  resources  of  the  accoucheur.  If  it  is  possible,  the  disease 
should  be  removed  as  much  as  can  be  safely  done  during  pregnancy, 
which  should  also  be  brought  to  an  end  before  the  full  period.  During 
labor,  incisions  should  form  a  preliminary  to  any  subsequent  proceed- 
ings that  may  be  necessary,  as  they  are,  at  the  worst,  not  likely  to 
increase  in  the  least  the  risk  the  patient  has  to  run,  and  they  may 
possibly  avert  more  serious  operations.  In  the  case  of  malignant 
disease  the  risk  of  serious  hemorrhage,  from  the  great  vascularity  of 
the  tissues,  must  not  be  forgotten,  and,  if  necessary,  means  must  be 
taken  to  check  this  by  local  styptics,  such  as  perchloride  of  iron.  If 
incision  fail,  and  the  state  of  the  patient  demands  speedy  delivery,  the 
forceps  may  be  applied,  and  Herman  thinks  they  are,  as  a  rule,  better 
than  turning.  He  also  maintains  that  there  is  little  difference  in  the 
risk  to  the  mothers  between  crauiotomy  and  the  Csesarean  section,  and 
that  the  possibility  of  saving  the  child  in  cases  in  which  incisions  have 
failed  should  induce  us  to  prefer  the  latter. 

[The  experience  of  our  country  is  decidedly  in  favor  of  the  improved 
Csesarean  operation  in  cases  of  cancer  of  the  cervix,  and  of  making  the 
section  before  the  pains  of  labor  have  commenced,  or  as  soon  as  pos- 
sible thereafter.  There  is  no  reason  wThy  such  cases  should  not  be 
saved,  as  the  uterine  wound  heals  readily,  to  which  I  can  bear  witness, 
having  seen  two  recoveries  under  Prof.  Goodell.  We  believe  this 
method  of  delivery  to  be  preferable  to  the  old  hysterotomy,  or  inci- 
sion of  the  cervix,  and  to  craniotomy,  as  the  passage  of  the  foetus 
through  the  diseased  os  uteri  is  attended  with  considerable  risk  to  the 
mother.  Several  women  and  children  have  been  saved  under  ccelio- 
hysterotomy  in  our  country. — ED.] 

Application  of  the  Forceps  within  the  Cervix. — Before  per- 
forming crauiotomy,  when  the  os  is  sufficiently  open,  a  cautious  appli- 
cation of  the  forceps  is  quite  justifiable.  Steady  and  careful  downward 
traction,  combined  with  digital  expansion,  has  often  enabled  a  head  to 
pass  with  safety  through  an  os  that  has  resisted  all  other  means  of 
dilatation,  and  the  destruction  of  the  child  has  thus  been  avoided. 
If,  indeed,  the  os  appear  to  be  dilatable,  this  procedure  may  advan- 
tageously be  adopted  before  incision,  and,  as  a  matter  of  fact,  it  is 
commonly  practised  in  the  Rotunda  Hospital.  An  operation  involv- 
ing, beyond  doubt,  of  itself  some  risk,  and  requiring  considerable 
operative  dexterity,  would  naturally  not  be  lightly  and  inconsiderately 
undertaken.  But  when  it  is  remembered  that  the  alternative  is  the 
destruction  of  the  child,  the  risk  of  exhaustion,  and  at  least  as  great 
mechanical  injury  to  the  mother,  its  difficulty  need  not  stand  in  the 
Way  of  its  adoption. 

Treatment  when  Occlusion  of  the  Os  exists. — When  the  os  is 
apparently  obliterated,  incision  is  the  only  resource.  Before  resorting 
to  it  the  patient  should  be  placed  under  chloroform,  and  the  entire 
lower  segment  of  the  uterus  carefully  explored.  Possibly  the  aperture 
may  be  found  high  up,  and  out  of  reach  of  an  ordinary  examination, 
or  we  may  detect  a  depression  corresponding  to  its  site.  A  small 
crucial  incision  may  then  be  made  at  the  site  of  the  os,  if  this  can  be 
ascertained ;  if  not,  at  the  most  prominent  portion  of  the  cervix.  Very 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.       371 

generally  the  pains  will  then  suffice  to  complete  expansion,  which  may 
be  further  aided  by  the  fluid  dilators. 

Ante-partum  Hour-glass  Contraction. — Dr.  Hosrner1  has  drawn 
attention  to  a  hitherto  undescribed  species  of  dystocia,  which  he  terms 
" ante-partum  hour-glass  contraction,"  and  which  he  believes  to  depend 
on  constriction  of  the  uterine  fibres  at  the  site  of  the  internal  os  uteri. 
Dr.  Blundell  refers  to  it  in  his  work  on  obstetrics  (1840)  under  the 
title  of  "Circular  Contraction  of  the  Middle  of  the  Womb."  Harris2 
doubts  its  limitation  to  the  internal  os  uteri,  and  terms  it  "tetanoid 
falciform  constriction  of  the  uterus.''  Whatever  its  site,  in  the  cases 
recorded  difficulties  of  the  most  formidable  kind  arose  from  this  cause. 
The  pelves  were  normal  and  the  presentations  natural,  yet  out  of  seven 
labors  four  ended  fatally,  two  before  delivery.  The  constriction  seems 
to  have  grasped  the  foetus  with  such  force  as  to  have  rendered  extraction, 
either  by  the  forceps  or  turning,  impossible.  I  have  no  personal  ex- 
perience of  this  complication,  which  must  fortunately  be  very  rare. 
The  introduction  of  the  hand,  the  patient  being  deeply  anaesthetized, 
would  probably  render  diagnosis  easy.  The  treatment  must  depend 
on  the  force  and  amount  of  constriction.  If  the  constriction  does  not 
relax  under  chloroform,  chloral,  or  the  injection  of  atropine  into  the 
site  of  constriction,  as  recommended  by  Horton  in  rigidity  of  the 
cervix,  turning  would  probably  be  our  best  resource.  Should  this  fail, 
the  Csesarean  section  may  be  required  to  effect  delivery,  as  happened  in 
a  case  recorded  by  Dr.  T.  A.  Foster,  of  Portland,  Maine.  Coalio- 
elytrotomy  is  obviously  unsuitable  for  such  cases. 

Bands  and  Cicatrices  in  the  Vagina. — Extreme  rigidity  of  the 
vagina,  or  bands  and  cicatrices  in  or  across  its  walls,  the  result  of  con- 
genital malformation,  of  injuries  in  former  labors,  or  of  antecedent 
disease,  occasionally  obstruct  the  second  stage.  There  is  seldom  any 
really  formidable  difficulty  from  this  cause,  since  the  obstruction  almost 
always  yields  to  the  pressure  of  the  presenting  part.  If  there  be  any 
considerable  extent  of  cicatrices  in  the  vagina,  artificial  assistance  may 
be  required.  If  we  should  be  aware  of  their  existence  during  preg- 
nancy, and  find  them  to  be  sufficiently  dense  and  extensive  to  be  likely 
to  interfere  with  delivery,  an  endeavor  may  be  made  to  dilate  them 
gradually  by  hydrostatic  bags  or  bougies.  If  they  be  not  detected 
until  labor  is  in  progress,  we  must  be  guided  in  our  procedure  by  the 
pressure  to  which  they  are  subjected.  It  may  then  be  necessary  to 
divide  them  with  a  knife,  and  to  hasten  the  passage  of  the  head  by  the 
forceps,  so  as  to  prevent  contusion  as  much  as  possible.  It  is  obvi- 
ously impossible  to  lay  down  any  positive  rules  for  such  rare  contin- 
gencies, the  treatment  suitable  for  which  must  necessarily  vary  much 
with  the  individual  peculiarities  of  the  case. 

Extreme  Rigidity  of  the  Perineum. — Extreme  rigidity  of  the 
perineum  is  often  dependent  upon  cicatricial  hardening  from  injury  in 
previous  labors.  This  may  greatly  interfere  with  its  dilatation ;  and 
if  laceration  seems  inevitable,  we  may  be  quite  justified  in  attempting 

1  Boston  Med.  and  Surg.  Journ.,  1878,  March  and  May. 
*  Harris's  note  to  second  American  edition. 


372  LABOR. 

to  avert  it  by  incision  of  the  margins  of  the  perineum,  on  the  principle 
of  a  clean  cut  being  always  preferable  to  a  jagged  tear. 

Labor  complicated  with  Tumor. — Occasionally  we  meet  with  very 
formidable  obstacles  from  tumors  connected  with  the  maternal  struc- 
tures. These  are  most  commonly  either  fibroid  or  ovarian,  although 
others  may  be  met  with,  such  as  malignant  growths  from  the  pelvic 
bones,  exostoses,  etc. 

Considering  the  frequency  with  which  women  suffer  from  fibroid 
tumors  of  the  uterus,  it  is  perhaps  somewhat  remarkable  that  these  do 
not  more  often  complicate  delivery.  Probably  women  so  affected  are 
not  apt  to  conceive.  Occasionally,  however,  cases  of  this  kind  cause 
much  anxiety.  Of  course,  those  cases  are  most  grave  in  which  tumors 
are  so  situated  as  to  encroach  upon  the  cavity  of  the  pelvis,  and  me- 
chanically obstruct  the  passage  of  the  child.  Even  those  in  which  this 
does  not  occur  are  by  no  means  free  from  danger,  for  interstitial  and 
sub-peritoneal  fibroids,  situated  in  the  upper  parts  of  the  uterus,  and 
leaving  the  pelvic  cavity  quite  uuimplicated,  may  interfere  with  the 
action  of  the  uterine  fibres,  prevent  subsequent  contraction,  cause  pro- 
fuse post-partum  hemorrhage,  or  even  predispose  to  rupture  of  the 
uterine  tissues.  Hence,  every  case  in  which  the  existence  of  uterine 
fibroids  has  been  ascertained  must  be  anxiously  watched.  The  risk  of 
hemorrhage  is  perhaps  the  greatest ;  for,  if  the  tumors  be  at  all  large, 
efficient  contraction  of  the  uterus  after  the  birth  of  the  child  must  be 
more  or  less  interfered  with.  Fortunately  it  is  not  so  common  as  might 
almost  be  expected.  Out  of  five  cases  recorded  in  the  Obstetrical  Trans- 
actions, two  of  which  were  in  my  own  practice,  no  hemorrhage  oc- 
curred ;  nor  does  it  seem  to  have  happened  in  any  of  the  twenty-six 
cases  collected  by  Magdelaine  in  his  thesis  on  the  subject.  I  recently 
saw  an  interesting  example  of  this  in  a  patient  whose  case  was  looked 
forward  to  with  much  anxiety,  in  consequence  of  the  existence  of 
several  enormous  fibroid  masses  projecting  from  the  fundus  and 
anterior  surface  of  the  body  of  the  uterus,  and  whose  labor  was,  never- 
theless, typically  normal  in  every  way.  Should  hemorrhage  occur 
after  delivery,  the  injection  of  styptic  solutions  would  probably  be 
peculiarly  valuable,  since  the  ordinary  means  of  promoting  contraction 
are  likely  to  fail. 

It  is  when  the  fibroid  growths  implicate  the  lower  uterine  zone  and 
the  cervical  region  that  the  greatest  difficulties  are  likely  to  be  met 
with.  The  practice  then  to  be  adopted  must  be  regulated  to  a  great 
extent  by  the  nature  of  each  individual  case.  If  it  be  possible  to  push 
the  tumor  above  the  pelvic  brim,  out  of  the  way  of  the  presenting  part, 
that,  no  doubt,  is  the  best  course  to  pursue,  as  not  only  clearing  the 
passage  in  the  most  effectual  way,  but  removing  the  tumor  from  the 
bruising  to  which  it  would  otherwise  be  subjected  when  pressed  between 
the  head  and  the  pelvic  walls,  which  seems  to  be  one  of  the  greatest 
dangers  of  this  complication.  This  manoeuvre  is  sometimes  possible 
in  what  seem  to  be  the  most  unpromising  circumstances.  An  interest- 
ing example  is  narrated  by  Sir  Spencer  Wells,1  who,  called  to  perform 

1  Obst.  Trans.,  1867,  vol.  ix.  p.  73. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.      373 

the  Csesarean  section,  succeeded,  although  not  without  much  difficulty, 
in  pushing  the  obstructing  mass  above  the  brim,  the  child  subsequently 
passing  with  ease.  I  have  myself  elsewhere  recorded  two  similar 
cases1  in  which  I  was  enabled  to  deliver  the  patient  by  pushing  up  the 
obstructing  tumor,  in  both  of  which  the  Caesarean  section  would  have 
been  inevitable  had  the  attempt  at  reposition  failed.  Therefore,  before 
resorting  to  more  serious  operative  procedures,  a  determined  effort  at 
pushing  the  tumor  out  of  the  way  should  be  made,  the  patient  being 
deeply  chloroformed,  and,  if  necessary,  upward  pressure  being  made 
by  the  closed  fist  passed  into  the  vagina.2 

Failing  this,  the  possibility  of  enucleating  the  tumor,  or  if  that  be 
not  possible,  of  removing  it  piecemeal  with  the  ecraseur,  should  be 
considered.  On  account  of  the  loose  attachments  of  these  growths, 
and  the  facility  with  which  they  can  be  removed,  in  this  way  in  the 
non-pregnant  state,  the  expedient  seems  certainly  well  worthy  a  trial, 
if  their  site  and  attachments  render  it  at  all  feasible.  Interesting 
examples  of  the  successful  performance  of  this  operation  are  recorded 
by  Danyau,  Braxton  Hicks,  Lomer,  and  Muude.  Should  it  be  found 
impracticable,  the  case  must  be  managed  in  reference  to  the  amount  of 
obstruction  ;  and  the  forceps,  craniotomy,  or  even  one  of  the  varieties 
of  abdominal  section  may  be  necessary.  Out  of  forty-five  old  Csesarean 
operations  collected  by  Harris  and  Sanger,  thirty-six  proved  fatal. 
Probably  Porro's  operation  would  give  the  patient  a  better  chance,  and 
of  this  several  successful  cases  are  recorded.  (  Vide  p.  233.) 

[The  Csesarean  operation,  with  removal  of  the  uterus,  is  preferable 
to  the  conservative  method,  and  less  apt  to  prove  fatal ;  besides  having 
the  additional  advantage  of  removing  the  diseased  growth.  In  nine 
Porro-Ciesarean  operations  in  fibroid  cases  in  the  United  States,  five 
ended  in  recovery,  and  five  children  were  saved.  The  last  four  cases 
in  order  recovered,  with  two  children  saved. — ED.] 

The  proportion  of  breech  presentations  in  cases  of  fibro-myoma 
complicating  delivery  is  much  larger  than  usual ;  out  of  one  hundred 
cases  Lefour3  observed  thirty-two  breech  presentations,  and  Chabazain 
gives  the  proportion  as  26  per  cent.  This  is  probably  due  to  the 
altered  shape  of  the  uterine  cavity  caused  by  the  tumor. 

Tumors  of  the  Ovaries. — The  next  most  common  class  of  obstruct- 
ing tumors  are  those  of  the  ovary  (Fig.  129),  and  it  is  apparently  not 
the  largest  of  these  which  are  most  apt  to  descend  into  the  pelvic 
cavity.  When  the  tumor  is  of  any  considerable  size,  its  bulk  is  such 
that  it  cannot  be  contained  in  the  true  pelvis,  and  it  rises  into  the 
abdominal  cavity  with  the  uterus.  Hence,  the  existence  of  the  tumor 
that  offers  the  most  formidable  obstacle  to  delivery  is  rarely  suspected 
before  labor  sets  in. 

In  order  to  estimate  the  results  of  the  various  methods  of  treatment, 
I  have  tabulated  fifty-seven  cases.4  In  thirteen,  labor  was  terminated 
by  the  natural  powers  alone ;  but  of  these,  six  mothers,  or  nearly  one- 

1  Ibid,  for  1877,  vol.  xix.  p.  101. 

2  This  procedure  is  objected  to  in  Dr.  John  Phillips's  paper  already  quoted,  but  It  seems  to  me  on 
insufficient  grounds 

3  E.  B'anc  :  Annal.  de  Gyn.,  torn.  xxxv.  p  197. 
«  Obst.  Trans.,  1867,  vol.  ix.  p.  69. 


374 


LABOR. 


half,  died.  In  favorable  contrast  with  these,  we  have  the  cases  in 
which  the  size  of  the  tumor  was  diminished  by  puncture.  These  are 
nine  in  number,  in  all  of  which  the  mother  recovered ;  five  out  of  the 
six  children  being  saved.  The  reason  of  the  great  mortality  in  the 
former  cases  is  apparently  the  bruising  to  which  the  tumor,  even  when 
small  enough  to  allow  the  child  to  be  squeezed  past  it,  is  necessarily 
subjected.  This  is  extremely  apt  to  set  up  a  fatal  form  of  diffuse  in- 
flammation, the  risk  of  which  was  long  ago  pointed  out  by  Ashwell,1 
who  draws  a  comparison  between  cases  in  which  such  tumors  have 
been  subjected  to  contusion  and  cases  of  strangulated  hernia ;  and  the 
cause  of  death  in  both  is  doubtless  very  similar.  This  danger 


is 


FIG.  129. 


Labor  complicated  by  ovarian  tumor. 


avoided  when  the  tumor  is  punctured,  so  as  to  become  flattened  between 
the  head  and  the  pelvic  walls.  On  this  account  I  think  it  should  be 
laid  down  as  a  rule  that  puncture  should  be  performed  in  all  cases  of 
ovarian  tumor  engaged  in  front  of  the  presenting  part,  even  when  it  is 
of  so  small  a  size  as  not  to  preclude  the  possibility  of  delivery  by  the 
natural  powers. 

In  five  of  the  fifty-seven  cases  it  was  found  possible  to  return  the 
tumor  above  the  pelvic  brim,  and  in  these  also  the  termination  was 
very  favorable,  all  the  mothers  recovering.  Should  puncture  not 
succeed,  and  it  may  fail  on  account  of  the  gelatinous  and  semi-solid 
nature  of  the  contents  of  the  cyst,  it  may  be  possible  to  dispose  of  the 
tumor  in  this  way,  even  when  it  seems  to  be  firmly  wedged  down  in 
front  of  ^  the  presenting  part,  and  to  be  hopelessly  fixed  in  its  unfavor- 
able position. 

Failing  either  of  these  resources,  it  may  be  necessary  to  resort  to 
craniotomy,  provided  the  size  of  the  tumor  precludes  the  possibility  of 
delivery  by  forceps. 

1  Guy's  Hospital  Reports,  1836,  No.  2,  p.  300. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.      375 

The  question  of  the  effect  on  labor  of  ovarian  tumor  which  does 
not  obstruct  the  pelvic  canal  is  one  of  some  interest,  but  there  are  not 
a  sufficient  number  of  cases  recorded  to  throw  much  light  on  it.  I 
am  disposed  to  think  that  labor  generally  goes  on  favorably.  What 
delay  there  is  depends  on  the  inefficient  action  of  the  accessory 
muscles  engaged  in  parturition,  on  account  of  the  extreme  distention 
of  the  abdomen. 

There  are  a  few  other  conditions  connected  with  the  maternal  struc- 
tures which  may  impede  delivery,  but  which  are  of  comparatively  rare 
occurrence. 

Vaginal  Cystocele. — Amongst  them  is  vaginal  cystocele,  consisting 
of  a  prolapse  of  the  distended  bladder  in  front  of  the  presentation, 
where  it  forms  a  tense  fluctuating  pouch  which  has  been  mistaken  for 
a  hydrocephalic  head,  or  for  the  bag  of  membranes.  This  complica- 
tion is  only  likely  to  arise  when  the  bladder  has  been  allowed  to  become 
unduly  distended  from  want  of  attention  to  the  voiding  of  urine  during 
labor.  The  diagnosis  should  not  offer  any  difficulty,  for  the  finger 
will  be  able  to  pass  behind,  but  not  in  front  of,  the  swelling,  and 
reach  the  presenting  part ;  while  the  pain  and  tenesmus  will  further 
put  the  practitioner  on  his  guard.  The  treatment  consists  in  emptying 
the  bladder ;  but  there  may  be  some  difficulty  in  passing  the  catheter, 
in  consequence  of  the  urethra  being  dragged  out  of  its  natural  direction. 
A  long  elastic  male  catheter  will  almost  always  pass,  if  used  with  care 
and  gentleness.  Should  it  be  found  impossible  to  draw  off  the  water 
— and  this  is  said  to  have  sometimes  happened — the  tense  pouch  might 
be  punctured  without  danger  by  the  fine  needle  of  an  aspirator  trocar, 
and  its  contents  withdrawn.  When  once  the  viscus  is  emptied,  it  can 
easily  be  pushed  above  the  presenting  part  in  the  intervals  between 
the  pains. 

Vesical  Calculus. — In  some  few  cases  difficulties  have  arisen  from 
the  existence  of  a  vesical  calculus.  Should  this  be  pushed  down  in 
front  of  the  head,  it  can  readily  be  understood  that  the  maternal 
structures  would  run  the  risk  of  being  seriously  bruised  and  injured. 
Should  we  make  out  the  existence  of  a  calculus — and,  if  the  presence 
of  one  be  suspected,  the  diagnosis  could  easily  be  made  by  means  of  a 
sound — an  endeavor  should  be  made  to  push  it  above  the  brim  of  the 
pelvis.  If  that  be  found  to  be  impossible,  no  resource  is  left  but  its 
removal,  either  by  crushing,  or  by  rapid  dilatation  of  the  urethra, 
followed  by  extraction.  Should  we  be  aware  of  the  existence  of  a 
calculus  during  pregnancy,  its  removal  should  certainly  be  undertaken 
before  labor  sets  in. 

Hernial  protrusion  in  Douglas's  space  may  sometimes  give  rise  to 
anxiety,  from  the  pressure  and  contusion  to  which  it  is  necessarily 
subjected.  An  endeavor  must  be  made  to  replace  it,  and  to  moderate 
the  straining  efforts  of  the  patient ;  and  it  may  even  be  advisable  to 
apply  the  forceps  so  as  to  relieve  the  mass  from  pressure  as  soon  as 
possible.  It  is,  however,  of  great  rarity.  Fordyce  Barker,  in  an  in- 
teresting paper  on  the  subject,1  records  several  examples,  and  states 

i  Amer.  Journ.  of  Obst.,  1876,  vol.  ix.  p.  177. 


376  LABOR. 

that  he  has  met  with  no  instance  in  which  it  has  led  to  a  fatal  result, 
either  to  mother  or  child,  although  it  cannot  but  be  considered  a  serious 
complication. 

Scybalous  masses  in  the  intestines  may  be  so  hard  and  impacted 
as  to  form  an  obstruction.  The  necessity  of  attending  to  the  state  of 
the  rectum  has  already  been  pointed  out.  Should  it  be  found  impos- 
sible to  empty  the  bowel  by  large  enemata,  the  mass  must  be  mechan- 
ically broken  down  and  removed  by  the  scoop. 

[Our  Southern  readers  are  aware  of  the  fact  that  their  lowest  class 
of  women  living  in  the  country  sometimes  eat  clay  as  a  remedy  for 
heartburn,  and  occasionally  in  excessive  quantities,  during  the  pregnant 
state.  Impacted  clay  in  the  lower  bowels  has  on  two  occasions  proved 
such  an  obstacle  to  delivery  that  the  Caesarean  operation  was  performed, 
one  case  occurring  in  Louisiana  and  the  other  in  Georgia,  in  the  years 
1866  and  1882  respectively,  after  labors  of  sixty  hours  and  three  days. 
The  first  case  recovered,  the  clay  being  removed  by  an  attack  of  diar- 
rhoea on  the  sixth  day.  The  second  died  of  convulsions  in  twenty 
days  after  the  uterine  and  abdominal  wounds  had  healed.  Under 
chloroform  about  two  and  a  half  pounds  of  sand  and  marl  were 
removed  three  days  after  the  operation. — ED.] 

CEdema  of  the  Vulva. — Excessive  cedematous  infiltration  of  the 
vulva  may  sometimes  cause  obstruction,  and  require  diminution  in  size, 
which  can  easily  be  eifected  by  numerous  small  punctures. 

Haematic  effusions  into  the  cellular  tissue  of  the  vulva  or  vagina 
form  a  grave  complication  of  labor.  Such  blood-swellings  are  most 
usually  met  with  in  one  or  both  labia,  or  under  the  vaginal  wall ;  in 
the  gravest  forms,  the  blood  may  extend  into  the  tissues  for  a  con- 
siderable distance,  as  in  the  case  recorded  by  Cazeaux,  where  it  reached 
upward  as  far  as  the  umbilicus  in  front,  and  as  far  as  the  attachment 
of  .the  diaphragm  behind. 

The  conditions  associated  with  pregnancy,  the  distention  and  en- 
gorgement to  which  the  vessels  are  subjected,  the  interference  with  the 
return  of  the  blood  by  the  pressure  of  the  head  during,  labor,  and  the 
violent  efforts  of  the  patient,  afford  a  ready  explanation  of  the  reason 
why  a  vessel  may  be  predisposed  to  rupture  and  admit  the  extravasa- 
tion of  blood. 

The  accident  is  fortunately  far  from  a  common  one,  although  a 
sufficient  number  of  cases  are  recorded  to  make  us  familiar  with  its 
symptoms  and  risks.  The  dangers  attending  such  effusions  would 
seem  to  be  great,  if  the  statistics  given  by  those  who  have  written  on 
the  subject  are  to  be  trusted.  Thus,  out  of  one  hundred  and  twenty- 
four  cases  collected  by  various  French  authors,  forty-four  proved  fatal. 
Fordyce  Barker  points  out  that,  since  the  nature  and  appropriate 
treatment  of  the  accident  have  been  more  thoroughly  understood,  the 
mortality  has  been  much  lessened ;  for  out  of  fifteen  cases  reported  by 
Scanzoni  only  one  died,  and  out  of  twenty-two  cases  he  had  himself 
seen,  two  died,  and  all  these  three  deaths  were  from  puerperal  fever, 
and  not  the  direct  result  of  the  accident.1 

1  The  Puerperal  Diseases,  p.  60. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.      377 

The  blood  may  be  effused  into  any  part  of  the  pelvic  cellular  tissue, 
or  into  the  labia.  The  accident  most  often  happens  during  labor  when 
the  head  is  low  down  in  the  pelvis,  not  unfrequently  just  as  it  is  about 
to  escape  from  the  vulva,  Hence  the  extravasation  is  more  often  met 
with  low  down  in  the  vagina,  and  more  frequently  in  one  of  the  labia 
than  in  any  other  situation.  I  have  met  with  a  case  in  which  I  had 
every  reason  to  believe  that  an  extravasation  of  blood  had  occurred 
within  the  tissues  immediately  surrounding  the  cervix.  It  is  natural 
to  suppose  that  a  varicose  condition  of  the  veins  about  the  vulva 
would  predispose  to  the  accident,  but  in  most  of  the  recorded  ex- 
amples this  is  not  stated  to  have  been  the  case.  Still,  if  varicose 
veins  exist  to  any  marked  degree,  some  anxiety  on  this  point  cannot 
but  be  felt. 

The  thrombus  occasionally,  though  rarely,  forms  before  delivery. 
Most  commonly  it  first  forms  toward  the  end  of  labor,  or  after  the 
birth  of  the  child.  In  the  latter  case  it  is  probable  that  the  laceration 
in  the  vessels  occurred  before  the  birth  of  the  child,  and  that  the 
pressure  of  the  presenting  part  prevented  the  escape  of  any  quantity 
of  blood  at  the  time  of  laceration. 

The  symptoms  are  not  by  any  means  characteristic.  Pain  of  a 
tearing  character,  occasionally  very  intense,  and  extending  to  the  back 
and  down  the  thighs,  is  very  generally  associated  with  the  formation 
of  the  thrombus.  If  a  careful  physical  examination  be  made,  the 
nature  of  the  case  can  readily  be  detected.  When  the  blood  escapes 
into  the  labium,  a  firm,  hard  swelling  is  felt  which  has  even  been  mis- 
taken for  the  foetal  head.  If  the  effusion  implicate  the  internal  parts 
only,  the  diagnosis  may  not  at  first  be  so  evident.  But  even  then  a 
little  care  should  prevent  any  mistake,  for  the  swelling  may  be  felt  in 
the  vagina,  and  may  even  form  an  obstacle  to  the  passage  of  the 
child.  Cazeaux  mentions  cases  in  which  it  was  so  extensive  as  to 
compress  the  rectum  and  urethra,  and  even  to  prevent  the  exit  of  the 
lochia.  In  some  cases  the  distention  of  the  tissues  is  so  great  that 
they  lacerate,  and  then  hemorrhage,  sometimes  so  profuse  as  directly 
to  imperil  the  life  of  the  patient,  may  occur.  The  bursting  of  the 
skin  may  take  place  some  time  subsequent  to  the  formation  of  the 
thrombus.  Constitutional  symptoms  will  be  in  proportion  to  the 
amount  of  blood  lost,  either  by  extravasation  cr  externally,  after 
the  rupture  of  the  superficial  tissues.  Occasionally  they  are  consider- 
able, and  are  the  same  as  those  of  hemorrhage  from  any  cause. 

The  terminations  of  thrombus  are  either  spontaneous  absorption, 
which  may  occur  if  the  amount  of  blood  extravasated  be  small ;  or 
the  tumor  may  burst,  and  then  there  is  external  hemorrhage ;  or  it 
may  suppurate,  the  contained  coagula  being  discharged  from  the  cavity 
of  the  cyst ;  or,  finally,  sloughing  of  the  superficial  tissues  has  occurred. 
The  treatment  must  naturally  vary  with  the  size  of  the  thrombus, 
and  the  time  at  which  it  forms.  If  it  be  met  with  during  labor, 
unless  it  be  extremely  small,  it  will  be  very  apt  to  form  an  obstruction 
to  the  passage  of  the  child.  Under  such  circumstances  it  is  clearly 
advisable  to  terminate  the  labor  as  soon  as  possible,  so  as  to  remove 
the  obstacle  to  the  circulation  in  the  vessels.  For  this  purpose  the 


378  LABOR. 

forceps  should  be  applied  as  soon  as  the  head  can  be  easily  Teached. 
If  the  tumor  itself  obstruct  the  passage  of  the  head,  or  if  it  be  of  any 
considerable  size,  it  will  be  necessary  to  incise  it  freely  at  its  most 
prominent  point  and  turn  out  the  coagula,  controlling  the  hemorrhage 
at  once  by  filling  the  cavity  with  cotton  wadding  saturated  in  a  solu- 
tion of  perchloride  of  iron,  while  at  the  same  time  digital  compression 
with  the  tips  of  the  fingers  is  kept  up.  By  this  means  pressure  is 
applied  directly  to  the  bleeding-point,  and  the  hemorrhage  can  be 
controlled  without  difficulty.  This  is  all  the  more  necessary  if  spon- 
taneous rupture  has  taken  place,  for  then  the  loss  of  blood  is  often 
profuse,  and  it  is  of  the  utmost  importance  to  reach  the  site  of  the 
hemorrhage  as  nearly  as  possible. 

If  the  thrombus  be  not  so  large  as  to  obstruct  delivery,  or  if  it  be  not 
detected  until  after  the  birth  of  the  child,  the  question  arises  whether 
the  case  should  not  be  left  alone,  in  the  hope  that  absorption  may  occur, 
as  in  most  cases  of  pelvic  hsernatocele.  This  expectant  treatment  is 
advised  by  Cazeaux,  and  it  seems  to  be  the  most  rational  plan  we  can 
adopt.  True,  it  may  take  a  longer  time  for  the  patient  to  convalesce 
completely  than  if  the  coagula  were  removed  at  once,  and  the  hemor- 
rhage restrained  by  pressure  on  the  bleeding-point;  but  this  disad- 
vantage is  more  than  counterbalanced  by  the  absence  of  risk  from 
hemorrhage,  and  of  septicaemia  from  the  suppuration  that  must 
necessarily  follow.  Softening  and  suppuration  may  in  many  cases 
occur  in  a  few  days,  necessitating  operation,  but  the  vessels  will  then 
be  probably  occluded,  and  the  risk  of  hemorrhage  be  much  lessened. 
The  late  Dr.  Fordyce  Barker,  however,  held  the  opposite  opinion, 
and  thought  that  the  proper  plan  was  to  open  the  thrombus  early, 
controlling  the  hemorrhage  in  the  manner  already  indicated,  unless 
the  thrombus  is  situated  high  in  the  vaginal  canal. 

Whenever  the  cavity  of  a  thrombus  has  been  opened,  either  by  in- 
cision or  by  spontaneous  softening  at  some  time  subsequent  to  its 
formation,  it  must  not  be  forgotten  that  there  is  considerable  risk  of 
septic  absorption.  To  avoid  this,  care  must  be  taken  to  use  antiseptic 
dressings  freely,  such  as  iodoform  powder  or  wool,  applied  directly  to 
the  part,  and  frequent  vaginal  injections  of  diluted  Condy's  fluid. 
Barker  laid  special  stress  upon  the  importance  of  not  removing 
prematurely  the  coagula  formed  by  the  styptic  applications,  for  fear 
of  secondary  hemorrhage,  but  of  allowing  them  to  come  away 
spontaneously. 

[Polypus. — Large  uterine  polypi  may  act  as  serious  obstacles  to 
delivery.  When  sufficiently  long  in  pedicle,  a  polypus  may  be  ex- 
truded before  the  head  of  the  foetus.  The  tumor  may  also  be  detached 
in  its  expulsion,  or  may  be  removed  by  an  ecraseur  if  recognized  in 
time ;  it  may  also  be  pushed  up  out  of  the  way  and  secured  by  bring- 
ing down  the  child.  I  once  replaced  a  large  polypus  that  was  extruded 
before  the  head,  and  the  woman  carried  it  two  years  longer ;  by  which 
time,  being  much  wasted  by  the  discharge,  she  made  up  her  mind  to 
have  it  removed. — ED.] 


DYSTOCIA    FROM    FCETUS. 


379 


CHAPTER    XI. 

DIFFICULT    LABOR    DEPENDING    ON    SOME    UNUSUAL 
CONDITION  OF  THE  FCETUS. 

Plural  Births. — The  subject  of  multiple  pregnancy  in  general 
having  already  been  fully  considered,  we  have  now  only  to  discuss  its 
practical  bearing  as  regards  labor.  Fortunately,  the  existence  of 
twins  rarely  gives  rise  to  any  serious  difficulty.  In  the  large  propor- 
tion of  cases  the  presence  of  a  second  foetus  is  not  suspected  until  the 
birth  of  the  first,  when  the  nature  of  the  case  is  at  once  apparent  from 
the  fact  of  the  uterus  remaining  as  large,  or  nearly  as  large,  as  it  was 
before. 

There  may  possibly  be  some  delay  in  the  birth  of  the  first  child, 
inasmuch  as  the  extreme  distention  of  the  uterus  may  interfere  with 


FIG.  130. 


Twin  pregnancy,  breech  and  head  presenting. 


its  thoroughly  efficient  action  ;  while,  in  addition,  the  uterine  pressure 
is  not  directly  conveyed  to  the  ovum  as  in  single  births,  but  in- 
directly through  the  amniotic  sac  of  the  second  child  (Fig.  130).  Such 
delay  is  especially  apt  to  arise  when  the  first  child  presents  by  the 
breech,  for,  even  if  the  body  be  expelled  spontaneously,  difficulty  is 
likely  to  occur  with  the  head,  since  the  uterus  docs  not  contract  upon 


380  LABOR. 

it  as  is  ordinarily  the  case.  Hence  the  intervention  of  the  accoucheur 
to  save  the  life  of  the  child,  by  the  extraction  of  the  head,  will  be 
almost  a  matter  of  necessity. 

In  the  majority  of  cases,  after  the  birth  of  the  first  child,  there  is  a 
temporary  lull  in  the  pains,  which  soon  recommence,  generally  in 
from  ten  to  twenty  minutes,  and  the  second  child  is  rapidly  expelled ; 
for  on  account  of  the  full  dilatation  of  the  soft  parts,  there  is  no 
obstacle  to  its  delivery.  Sometimes  there  is  a  considerable  interval 
before  the  pains  recur,  and  instances  are  recorded  in  which  even 
several  days  elapsed  between  the  births  of  the  two  children. 

Treatment. — In  most  cases  the  management  of  twins  does  not  diifer 
from  that  of  ordinary  labor.  As  soon  as  we  are  certain  of  the  exist- 
ence of  a  second  foetus,  we  should  inform  the  bystanders,  but  not 
necessarily  the  mother,  to  whom  the  news  might  prove  an  unpleasant 
and  even  dangerous  shock.  Then,  having  taken  care  to  tie  the  cord 
of  the  first  child  for  fear  of  vascular  communication  between  the  pla- 
centa?, our  duty  is  to  wait  for  a  recurrence  of  the  pains.  If  these  come 
on  rapidly,  and  the  presentation  of  the  second  foetus  be  normal,  its 
birth  is  managed  in  the  usual  way. 

If  there  be  any  unusual  delay,  we  have  to  consider  the  proper  course 
to  pursue,  and  on  this  the  opinions  of  authorities  diifer  greatly.  Some 
advise  a  delay  of  several  hours,  and  even  more,  if  pains  do  not  recur 
spontaneously ;  while  others — Murphy,  for  example — recommend  that 
the  second  child  should  be  delivered  at  once.  Either  extreme  of  prac- 
tice is  probably  wrong,  and  the  safest  and  best  course  is,  doubtless,  the 
median  one.  The  second  point  to  bear  In  mind  is,  that  in  multiple 
pregnancy,  on  account  of  the  extreme  distention  of  the  uterus,  there  is 
a  tendency  to  inertia,  and  consequently  to  post-partum  hemorrhage ; 
and  that,  therefore,  it  is  better  that  the  birth  of  the  second  child  should 
be  delayed,  even  for  a  considerable  time,  rather  than  that  the  patient 
should  run  the  risk  attending  an  empty  and  uncontracted  uterus.  If, 
however,  uterine  action  be  present,  there  is  an  obvious  advantage  in 
the  delivery  of  the  second  child  before  the  dilatation  of  the  passages 
passes  off. 

The  best  plan  would  seem  to  be,  if,  after  waiting  a  quarter  of  an 
hour,  labor-pains  do  not  occur,  to  try  and  induce  them  by  uterine  fric- 
tion and  pressure,  and  by  the  administration  of  a  dose  of  ergot,  to 
which,  as  there  can  be  no  obstacle  to  the  rapid  birth  of  the  second 
child,  there  can  be  now  no  objection.  The  membranes  of  the  second 
child  should  always  be  ruptured  at  once,  if  easily  within  reach,  as  one 
of  the  speediest  means  of  inducing  contraction.  If  no  progress  be 
made,  and  speedy  delivery  be  indicated — a  necessity  which  may  arise 
either  from  the  exhausted  state  of  the  patient,  the  presence  of  hemor- 
rhage, extremely  feeble  pulsations  of  the  foetal  heart  (showing  that  the 
life  of  the  second  child  is  endangered),  or  malpresentation  of  the 
second  foetus — turning  is  probably  the  readiest  and  safest  expedient. 
Under  such  circumstances  the  operation  is  performed  with  great  ease, 
since  the  passages  are  amply  dilated.  After  bringing  down  the  feet, 
the  birth  of  the  body  should  be  slowly  effected,  with  the  view  of  insur- 
ing as  complete  subsequent  contraction  as  possible.  If  the  head  has 


DYSTOCIA    FROM    F(ETUS.  381 

descended  in  the  pelvis,  of  course  turning  is  impossible,  and  the  forceps 
must  be  applied. 

Difficulties  arising-  from  Locked  Twins. — Occasionally  very 
serious  difficulties  arise  from  parts  of  both  foetuses  presenting  simulta- 
neously, and  thus  impeding  the  entrance  of  either  child  into  the  pelvis, 
or  getting  locked  together,  so  as  to  render  delivery  impossible  \yithout 
artificial  aid.  Such  difficulties  are  not  apt  to  arise  in  the  more  ordi- 
nary cases,  in  which  each  child  has  its  own  bag  of  membranes,  since 
then  the  foetuses  are  kept  entirely  separate ;  but  in  those  in  which  the 
twins  are  contained  in  a  common  amniotic  cavity,  or  in  which  both 
sacs  have  burst  simultaneously.  They  are  very  puzzling  to  the  obste- 
trician, and  it  may  be  far  from  easy  to  discover  the  cause  of  the 
obstruction.  Nor  is  it  possible  to  lay  down  any  positive  rules  for  their 
management,  which  must  be  governed,  to  a  considerable  extent,  by  the 
circumstances  of  each  individual  case. 

FIG.  131. 


Shows  head-locking,  both  children  presenting  head  first.    (After  BARNES.) 

Sometimes  both  heads  present  simultaneously  at  the  brim,  and  then 
neither  can  enter  unless  they  be  unusually  small  or  the  pelvis  very 
capacious,  when  both  may  descend;  or  rather  the  first  head  may 
descend  low  into  the  pelvic  cavity,  and  then  the  second  head  enters  the 
brim,  and  gets  jammed  against  the  thorax  of  the  first  child  (Fig.  131). 

Reimann  l  relates  a  curious  example  of  this,  in  which  he  delivered 
the  head  first  with  the  forceps,  but  found  the  body  would  not  follow, 
and,  on  examination,  a  second  head  was  found  in  the  pelvis.  He  then 
applied  the  forcep's  to  the  second  head  ;  the  body  of  the  first  child  was 
then  born,  and  afterward  that  of  the  second.  Such  a  mechanism  must 

1  Arch.  f.  Gynak.,  1871,  Bd.  ii.  p.  99. 


382  LABOR. 

clearly  have  been  impossible  unless  the  pelvis  had  been  extremely 
large. 

Whenever  both  heads  are  felt  at  the  brim,  it  will  generally  be  found 
possible  to  get  one  out  of  the  way  by  appropriate  manipulation,  one 
hand  being  passed  into  the  vagina,  the  other  aiding  its  action  from 
without.  Then  the  forceps  may  be  applied  to  the  other  head,  so  as  to 
engage  it  at  once  in  the  pelvic  cavity.  If  both  have  actually  passed 
into  the  pelvis,  as  in  the  case  just  alluded  to,  the  difficulty  will  be 
much  greater.  It  will  generally  be  easier  to  push  up  the  second  head 
while  the  lower  is  drawn  out  by  the  forceps,  than  to  deliver  the  second, 
leaving  the  first  in  situ. 

In  other  cases  a  foot  or  a  hand  may  descend  along  with  the  head, 
and  even  the  four  feet  may  present  simultaneously.  The  rule  in  the 
former  case  is  to  push  the  part  descending  with  the  head  out  of  the 
way,  and  in  the  latter  to  disengage  one  child  as  soon  as  possible. 
Great  care  is  necessary,  or  we  might  possibly  bring  down  the  limbs  of 
separate  children. 

The  most  common  kind  of  difficulty  is  when  the  first  child  presents 
by  the  breech,  and  is  delivered  as  far  as  the  head,  which  is  then  found 
to  be  locked  with  the  head  of  the  second  child,  which  has  descended 
into  the  pelvic  cavity  (Fig.  132). 

Here  it  is  clear  that  the  obstruction  must  be  very  great,  and,  unless 
the  children  are  extremely  small,  insuperable.  The  first  endeavor 
should  be  to  disentangle  the  heads ;  this  is  sometimes  feasible  if  the 
second  be  not  deeply  engaged  in  the  pelvis,  and  the  hand  be  passed  up 
so  as  to  push  it  out  of  the  way.  This  will  but  rarely  succeed  ;  then  it 
may  be  possible  to  apply  the  forceps  to  the  second  head  and  drag  it 
past  the  body  of  the  first  child,  and  this  is  the  method  recommended 
by  Reiinann,  who  has  written  an  excellent  paper  on  the  subject.1 
Generally  the  sacrifice  of  one  of  the  children  is  essential,  and  as  the 
body  of  the  first  child  must  have  been  born  for  some  time,  it  is  prob- 
able that  the  pressure  to  which  it  has  been  subjected  will  have  already 
imperilled,  if  it  has  not  destroyed,  its  life,  and  therefore  the  plan 
usually  recommended  is  to  decapitate.  This  can  be  easily  done  with 
scissors  or  a  wire  Scraseur,  after  which  the  second  child  is  expelled 
without  difficulty,  leaving  the  head  of  the  first  in  utero  to  be  subse- 
quently dealt  with. 

Another  mode  of  managing  these  cases  is  to  perforate  the  upper  head 
and  draw  it  past  the  lower  with  the  cephalotribe  or  craniotomy  forceps. 
This  plan  has  the  disadvantage  of  probably  sacrificing  both 'children, 
since  the  other  child  can  hardly  survive  the  pressure  and  delay,  whereas 
the  former  plan  gives  the  second  child  a  fair  chance  of  being  born  alive. 

Double  Monsters. — In  connection  with  the  subject  of  twin  labor 
we  may  consider  those  rare  cases  in  which  the  bodies  of  the  foetuses  are 
partially  fused  together.  The  mechanism  and  management  of  delivery 
in  cases  of  double  monstrosity  have  attracted  comparatively  little  atten- 
tion, no  doubt  because  authors  have  considered  them  matters  of  curi- 
osity merely,  rather  than  of  practical  importance. 

1  American  Journal  of  Obstetrics,  1877,  vol.  x.  p.  47. 


DYSTOCIA    FROM    FCBTUS. 


S83 


The  frequent  occurrence  of  such  monstrosities  in  our  museums,  and 
the  numerous  cases  scattered  through  our  periodical  literature,  are 
sufficient  to  show  that  they  are  not  so  very  rare  as  we  might  be 
inclined  to  imagine  ;  and,  as  they  are  likely  to  give  rise  to  formidable 
difficulties  in  delivery,  it  cannot  be  unimportant  to  have  a  clear  idea 
of  the  usual  course  taken  by  Nature  in  effecting  such  births,  with  a 
view  of  enabling  us  to  assist  in  the  most  satisfactory  manner  should  a 
similar  case  come  under  our  observation. 


FIG.  132. 


Shows  head-locking,  first  child  coming  feet  first ;  impaction  of  heads  from  wedging  in  brim.  D. 
Apex  of  wedge.  E.  c.  Base  of  wedge,  which  cannot  enter  brim.  A.  B.  Line  of  decapitation  to 
decompose  wedge,  and  enable  head  of  second  child  to  pass.  (After  BARNES.) 

Unfortunately,  the  authors  who  have  placed  on  record  the  birth  of 
double  monsters  have  generally  occupied  themselves  more  with  a 
description  of  the  structural  peculiarities  of  the  foetuses  than  with  the 
mechanism  of  their  delivery;  so  that,  although  the  cases  to  be  met  with 
in  medical  literature  are  very  numerous,  comparatively  few  of  them 
are  of  real  value  from  an  obstetric  point  of  view.  Still,  I  have  been 


384  LABOR. 

able  to  collect  the  details  of  a  considerable  number1  in  which  the  his- 
tory of  the  labor  is  more  or  less  accurately  described ;  and  doubtless  a 
more  extensive  research  would  increase  the  list. 

Double  Monstrosity  may  be  Divided  into  Pour  Classes. — For 
obstetric  purposes  we  may  confine  our  attention  to  four  principal 
varieties  of  double  monstrosity,  which  are  met  with  far  more  frequently 
than  any  others.  These  are  : 

A.  Two  nearly  separate  bodies  united  in  front  to  a  varying  extent, 
by  thorax  or  abdomen. 

"  B.  Two  nearly  separate  bodies  united  back  to  back  by  the  sacrum 
and  lower  part  of  the  spinal  column. [2] 

C.  Dicephalous  monsters,  the  bodies  being  single  below,  but  the 
heads  separate.  [3] 

D.  The  bodies  separate  below,  but  the  heads  partially  united. 
This  classification  by  no  means  includes  all  the  varieties  of  monsters 

that  we  may  meet  with.  It  does,  however,  include  all  that  are  likely 
to  give  rise  to  much  difficulty  in  delivery ;  and  all  the  cases  I  have 
collected  may  be  placed  under  one  of  these  divisions. 

The  first  point  that  strikes  us  in  looking  over  the  history  of  these 
deliveries  is  the  frequency  with  which  they  have  been  terminated  by 
the  natural  powers  alone,  without  any  assistance  on  the  part  of  the 
accoucheur.  Thus,  out  of  the  31  cases,  no  less  than  20  were  delivered 
naturally,  and  apparently  without  much  trouble.  Nothing  can  better 
show  the  wonderful  resources  of  Nature  in  overcoming  difficulties  of  a 
very  formidable  kind. 

It  is  pretty  generally  assumed  by  authors  that  the  children  are 
necessarily  premature,  and  therefore  of  small  size,  and  that  delivery 
before  the  full  term  is  rather  the  rule  than  the  exception.  Dug6s 
states  that  the  children  are  often  dead,  and  that  putrefaction  has  taken 
place,  which  facilitates  their  expulsion.  Both  these  assumptions  seem 
to  me  to  have  been  made  without  sufficient  authority,  and  not  to  be 
borne  out  by  the  recorded  facts.  In  only  one  of  the  3i  cases  is  it  men- 
tioned that  the  children  were  premature ;  nor  is  there  any  sufficient 
reason  that  I  can  see  why  labor  should  commence  before  the  full  term 
of  gestation. 

Class  A. — By  far  the  greatest  number  are  included  in  the  first 
class — that  in  which  the  bodies  are  nearly  separate,  but  united  by  some 
part  of  the  thorax  or  abdomen.  This  is  the  division  which  includes 
the  celebrated  Siamese  Twins,  an  account  of  whose  birth,  I  may  ob- 
serve, I  have  not  been  able  to  discover.4  [It  also  includes  the  Orissa 

1  Obst.  Trans.,  1867,  vol.  viii.  p.  300. 

*  [As  in  the  Carolina  Sisters  (colored),  now  living  at  the  age  of  forty-two;  and  the  Bohemian 
Sisters,  Blazek,  born  January  20,  1878,  also  still  living.  Rosalie  Blaze'k  came  by  the  head— the 
pelvis  and  four  legs  followed  the  delivery  of  her  thorax— and  finally  the  chest  and  head  of  Josepha 
were  delivered.— ED.] 

a  I^As  in  the  Tocci  Brothers,  now  living,  who  were  born  at  Locana,  Italy,  on  October  4,  1877. 
Their  analogue,  the  "Rita-Christina,"  of  Sassari,  Island  of  Sardinia,  1829,  lived  eight  months  - 
March  12th  to  November  23d. -Eo.] 

«  The  mother  of  these  twins  was  a  Chinese  half-breed,  short,  and  with  a  broad  pelvis,  and  had 
borne  several  children  previously.  She  stated  on  several  occasions,  in  conversation  with  parties 
in  Siam,  that  the  twins  were  born  reversed,  the  feet  of  one  being  followed  by  the  head  of  the  other, 
and  that  they  were  very  small  and  feeble  at  birth  and  for  several  months  afterward.  The  twins 
confirmed  this  statement  by  affirming  that  they  could,  when  little  boys  at  play  on  the  ground,  turn 
themselyes  end  for  end  upon  the  ensiforra  attachment  up  to  the  age  of  ten  or  twelve,  the  attach- 
ment being  then  soft  and  pliable.— Harris's  note  to  second  American  edition. 

[These  twins  were  three-quarters  Chinese,  their  father  being  a  Chinaman  Their  mother  was 
scan  by  Dr.  W.  S.  W.  Ruschenberger,  in  Bangkok,  and  described  as  above.— ED.] 


DYSTOCIA    FROM    FCETUS.  385 

Sisters,  of  India,  recently  shown  in  London,  nearly  four  years  old. 
Their  birth  was  a  very  easy  one,]  Out  of  the  31  cases,  19  come  under 
this  heading.  The  details  of  the  labors  are  briefly  as  follows  :  1  died 
undelivered  ;  8  were  terminated  by  the  natural  powers  (in  three  of 
which  the  feet,  and  in  three  the  head  presented,  in  two  the  presentation 
is  doubtful);  6  were  delivered  by  turning,  or  by  traction  on  the  lower 
extremities ;  4  were  delivered  instrurnentally. 

The  details  of  the  cases  in  which  the  feet  presented,  or  in  which 
turning  was  performed,  clearly  show  that  footling  presentation  was 
by  1'ar  the  most  favorable,  and  it  is  fortunate  that  the  feet  often  present 
naturally.  The  inference,  of  course,  is  that  version  should  be  resorted 
to  whenever  any  other  presentation  is  met  with  in  cases  of  double 
monstrosity  of  this  type  ;  but,  unfortunately,  this  rule  could  rarely  be 
carried  into  execution,  since  we  possess  no  means  of  diagnosing  the 
junction  of  the  fetuses  at  a  sufficiently  early  stage  of  labor  to  admit 
of  turning  being  performed.  It  is  only  under  exceptionally  favorable 
circumstance's  that  this  can  be  done  ;  as,  for  example,  in  a  case  recorded 
by  Molas,  in  which  both  heads  presented,  but  neither  would  enter  the 
brim  of  the  pelvis. 

The  great  difficulty  must,  of  course,  be  in  the  delivery  of  the  heads, 
for  in  all  the  recorded  cases,  with  one  exception,  the  bodies  have  passed 
through  the  pelvis  parallel  to  each  other  with  comparative  ease  until 
the  necks  have  appeared,  and  then,  as  a  rule,  they  could  be  brought 
no  further.  It  is  clear  that  the  remainder  of  the  foetuses  could  no 
longer  pass  simultaneously ;  and,  were  direct  traction  continued,  the 
heads  would  be  inextricably  fixed  above  the  brim.  In  accordance 
with  the  direction  of  the  pelvic  axes  the  posterior  head  must  first 
engage  in  the  inlet ;  and,  in  order  to  effect  this,  it  will  be  necessary  to 
carry  the  bodies  of  the  children  well  over  the  abdomen  of  the  mother. 
This  seems  to  be  a  point  of  primary  importance.  It  wrould  also  be 
advisable  to  see  that  the  bodies  are  made  to  pass  through  the  pelvis 
with  their  backs  in  the  oblique  diameter.  By  this  means  more  space 
is  gained  than  if  the  backs  were  placed  antero-posteriorly ;  while,  at 
the  same  time,  there  is  less  chance  of  the  heads  hitching  against  the 
promontory  of  the  sacrum  and  symphysis  pubis,  which  otherwise  would 
be  very  apt  to  occur. 

When  the  head  presents,  and  the  labor  is  terminated  by  the  natural 
powers,  delivery  seems  to  be  accomplished  in  one  of  two  ways. 

In  the  first  and  more  common,  the  head  and  shoulders  of  one  child 
are  born,  its  breech  and  legs  being  subsequently  pushed  through  the 
pelvis  by  a  process  similar  to  that  of  spontaneous  evolution  ;  and, 
afterward,  the  second  child  probably  passes  footling  without  much 
difficulty. 

Barkow  relates  a  case  in  which  both  heads  were  delivered  by  the 
forceps,  the  bodies  subsequently  passing  simultaneously.  Two  similar 
instances  are  recorded  in  the  third  and  sixth  volumes  of  the  Obstetrical 
Transactions.  When  delivery  takes  places  in  this  manner,  the  head 
of  the  second  child  must  fit  into  the  cavity  formed  by  the  neck  of  the 
first,  and  the  pelvis  must  necessarily  be  sufficiently  roomy  to  admit  of 
the  expulsion  of  the  head  of  the  second  child  while  its  cavity  is  dimin- 

25 


386  LABOR. 

ished  in  size  by  the  presence  of  the  neck  and  snoulders  of  the  first. 
Either  of  these  processes  must  obviously  require  exceptionally  favor- 
able conditions  as  regards  the  size  of  the  child  and  the  pelvis ;  and  the 
difficulty  in  the  way  of  delivery  must  be  much  greater  than  when  the 
lower  extremities  present.  Therefore,  I  think  the  rule  should  be  laid 
down  that,  when  the  nature  of  the  case  is  made  out  (and  for  the  pur- 
pose of  accurate  diagnosis  a  complete  examination  under  anaesthesia 
should  be  practised),  turning  should  be  performed,  and  the  feet  brought 
down. 

In  the  event  of  its  being  found  impossible  to  effect  delivery  after  a 
considerable  portion  of  the  bodies  is  born,  no  resource  remains  but  the 
mutilation  of  the  body  of  one  child,  so  as  to  admit  of  the  passage  of 
the  other.  This  was  found  necessary  in  one  case  in  which  the  children 
presented  by  the  feet,  and  were  born  as  far  as  the  thorax,  but  could 
get  no  further.  The  body  of  the  anterior  child  was  removed  by  a 
circular  incision  as  far  as  it  had  been  expelled,  which  allowed  the 
remaining  portion,  consisting  of  the  head  and  shoulders,  to  re-enter 
the  uterus ;  after  this  the  posterior  child  was  easily  extracted,  and  the 
mutilated  foetus  followed  without  difficulty. 

Class  B. — In  class  B,  in  which  the  children  are  united  back  to  back, 
[4]  cases  are  recorded,  all  of  which  were  delivered  by  the  natural 
powers  [and  alive].  One  of  these  is  the  case  of  Judith  and  Helene, 
the  celebrated  Hungarian  twins,  who  lived  to  the  age  of  twenty-one. 
Helene  was  born  as  far  as  the  umbilicus,  and,  after  the  lapse  of  three 
hours,  her  breech  and  legs  descended.  Judith  was  expelled  imme- 
diately afterward,  her  feet  descending  first.  [']  Exactly  the  same 
process  occurred  in  a  case  described  by  M.  Norman,  the  children  being 
also  born  alive,  and  dying  on  the  ninth  day.  [The  fourth  case  is 
that  of  the  Bohemian  sisters  already  mentioned. — ED.] 

It  is  probable  that  labor  is  easier  in  this  class  of  double  monsters 
than  in  the  former,  because  the  children  are  so  joined  that  there 
is  no  necessity  for  the  bodies  to  be  parallel  to  each  other  during 
birth  when  the  head  presents,  and  after  the  birth  of  the  head  and 
shoulders  of  the  first  child,  its  breech  and  lower  extremities  are 
evidently  pushed  down  and  expelled  by  a  process  of  spontaneous  evo- 
lution. If  the  feet  originally  presented,  the  mechanism  of  delivery 
and  the  rules  to  be  followed  would  be  the  same  as  in  class  A ;  but  the 
difficulty  would  probably  be  greater,  since  the  juncture  is  not  so  flexible, 
and  a  more  complete  parallelism  of  the  bodies  would  be  necessary 
during  extraction. 

Class  C. — In  class  C,  that  of  the  dicephalous  monters,  I  have  found 
the  description  of  the  birth  of  eight  cases,  three  of  which  were  termi- 
nated by  the  natural  powers.  In  two  of  these,  the  process  of  evolution 
was  the  main  agent  in  delivery;  one  head  being  born  and  becoming 
fixed  under  the  arch  of  the  pubes,  the  body  being  subsequently  pushed 
past  it,  and  the  second  head  following  without  difficulty.  This  process 

[i  The  celebrated  Carolina  twins,  born  July  11, 1851,  and  still  living,  were  brought  into  the  world 
py  the  same  method,  but  the  mother,  having  a  large  pelvis,  had  "  a  brief  and  easy  "  delivery.  The 
larger  of  the  two  girls  also  came  first,  as  in  the  Tzoni  case  of  1701.  These  twins  are  twice  as  old  as 
the  Hungarian  sisters  were  at  death.— ED.] 


DYSTOCIA    FROM    FCETUS.  387 

failing,  the  proper  course  is  to  decapitate  the  first-born  head,  and  then 
bring  down  the  feet  of  the  child,  when  delivery  can  be  accomplished 
with  ease.  This  was  the  course  adopted  in  two  out  of  the  eight  cases ; 
and  it  may  be  done  with  the  less  hesitation  since,  from  their  structural 
peculiarities,  it  is  extremely  improbable  that  monsters  of  this  kind 
should  survive.  In  the  third  case,  terminated  naturally,  the  heads 
were  said  to  have  been  born  simultaneously,  but  it  seems  probable  that 
the  one  head  lay  in  the  hollow  formed  by  the  neck  of  the  other,  and  so 
rapidly  followed  it.  If  the  feet  presented,  the  case  might  be  managed 
in  the  same  manner  as  in  class  A. 

[Of  class  C,  I  have  a  record  of  twelve  cases,  eight  united  boys,  and 
four  girls,  born  from  1316  to  1877,  inclusive.  Five  of  the  male  twins, 
and  two  of  the  female,  were  born  alive.  The  male  twins  lived  re- 
spectively a  few  minutes,  a  few  days,  fifteen  days,  twenty-eight  years, 
and  fifteen  years  (still  living).  The  two  female  twins  lived  one  day, 
and  eight  months. — ED.] 

Class  D. — Monstrosities  of  class  D,  in  which  the  heads  are  united, 
the  bodies  being  distinct,  appear  to  be  the  most  uncommon  of  all ;  and 
I  can  find  the  description  of  delivery  in  only  two  cases.  .  One  of  these 
gave  rise  to  great  difficulty ;  the  labor  in  the  other  was  easy.  We 
should  scarcely  anticipate  much  difficulty  in  the  birth  of  monsters  of 
this  type ;  for,  if  the  head  presented  and  would  not  pass,  we  should 
naturally  perform  craniotomy ;  and  if  the  bodies  came  first,  the  delivery 
of  the  monstrous  head  could  readily  be  accomplished  by  perforation. 

The  result  to  the  mothers  in  all  these  cases  seems  to  have  been 
very  favorable.  There  is  only  one  in  which  the  death  of  the  mother 
is  recorded ;  and  although  in  many  the  result  is  not  mentioned,  we 
may  fairly  assume  that  recovery  took  place. 

Among  difficulties  in  labor,  some  of  the  most  important  are  due  to 
morbid  conditions  of  the  foetus  itself. 

Intra-uterine  Hydrocephalus. — Of  these,  the  most  common,  as 
well  as  the  most  serious,  is  caused  by  intra-uterine  hydrocephalus 
(giving  rise  to  a  collection  of  watery  fluid  within  the  cranium),  by 
which  the  dimensions  of  the  child's  head  are  enormously  increased, 
and  the  due  relations  between  it  and  the  pelvic  cavity  entirely  de- 
stroyed (Fig.  133). 

Fortunately  this  disease  is  of  comparatively  rare  occurrence,  for  it  is 
one  of  great  gravity  both  as  regards  the  mother  and  child.  As  regards 
the  mother,  the  serious  character  of  the  complication  is  proved  by  the 
statistics  of  Dr.  Thomas  Keith,  then  of  Edinburgh,  who  found  that  out 
of  seventy-four  cases  no  less  than  sixteen  were  accompanied  by  rupture 
of  the  uterus.  The  reason  of  the  danger  to  which  the  mother  is 
subjected  is  obvious.  In  some  few  cases,  indeed,  the  head  is  so  com- 
pressible that,  provided  the  amount  of  contained  fluid  be  small,  it  may 
be  sufficiently  diminished  in  size,  by  the  moulding  to  which  it  is  sub- 
jected, to  admit  of  its  being  squeezed  through  the  pel  vis.  [!]  In  the 
majority  of  cases,  however,  the  size  of  the  head  is  too  great  for  this 
to  occur.  The  uterus  therefore  exhausts  itself,  and  may  even  rupture, 

P  I  once  removed  a  measured  pint  of  hydrocephalic  serum  from  a  foetus  that  was  born  dead, 
without  assistance. — ED.] 


388 


LABOR. 


in  the  vain  endeavor  to  overcome  the  obstacle ;  while  the  large  and 
distended  head  presses  firmly  on  the  cervix,  or  on  the  pelvic  tissues, 
if  the  os  be  dilated,  and  all  the  evil  effects  of  prolonged  compression 
are  apt  to  follow. 


FIG.  133. 


Labor  impeded  by  bydrocephalus. 

Diagnosis. — The  diagnosis  of  intra-uterine  hydrocephalus  is  by  no 
means  so  easy  as  the  description  in  obstetric  works  would  lead  us  to 
believe.  It  is  true  that  the  head  is  much  larger  and  more  rounded  in 
its  contour  than  the  healthy  foetal  cranium,  and  also  that  the  sutures 
and  fontanelles  are  more  wide,  and  admit  occasionally  of  fluctuation 
being  perceived  through  them.  Still  it  is  to  be  remembered  that  the 
head  is  always  arrested  above  the  brim,  where  it  is  consequently  high 
up  and  difficult  to  reach,  and  where  these  peculiarities  are  made  out 
with  much  difficulty.  As  a  matter  of  fact,  the  true  nature  of  the  case  is 
comparatively  rarely  discovered  before  delivery ;  thus  Chaussier1  found 
that  in  more  than  one-half  of  the  cases  he  collected,  an  erroneous 
diagnosis  had  been  made. 

Whenever  we  meet  with  a  case  in  wThich  either  the  history  of  pre- 
vious labor,  or  a  careful  examination,  convinces  us  that  there  is  no 
obstacle  due  to  pelvic  deformity,  in  which  the  pains  are  strong  and 
forcing,  but  in  which  the  head  persistently  refuses  to  engage  in  the 
brim,  we  may  fairly  surmise  the  existence  of  hydrocephalus.  Nothing, 
however,  short  of  a  careful  examination  under  anaesthesia,  the  whole 
hand  being  passed  into  the  vagina  so  as  to  explore  the  presenting  part 
thoroughly,  will  enable  us  to  be  quite  sure  of  the  existence  of  this  com- 
plication. Under  these  circumstances  such  a  complete  examination  is 
not  only  justified  but  imperative ;  and,  when  it  has  been  made,  the 
difficulties  of  diagnosis  are  lessened,  for  then  we  may  readily  make  out 

1  Gazette  Medicale,  18r>4. 


DYSTOCIA    FROM    FO3TUS.  389 

the  large  round  mass,  softer  and  more  compressible  than  the  healthy 
head,  the  widely  separated  sutures,  and  the  fluctuating  fontanelles. 

In  a  considerable  proportion  of  cases — as  many,  it  is  said,  as  one 
out  of  five — the  foetus  presents  by  the  breech.  The  diagnosis  is  then 
still  more  difficult ;  for  the  labor  progresses  easily  until  the  shoulders 
are  born,  when  the  head  is  completely  arrested,  and  refuses  to  pass 
with  any  amount  of  traction  that  is  brought  to  bear  on  it.  Even  the 
most  careful  examination  may  not  enable  us  to  make  out  the  cause  of 
the  delay,  for  the  finger  will  impinge  on  the  comparatively  firm  base 
of  the  skull,  and  may  be  unable  to  reach  the  distended  portion  of  the 
cranium.  At  this  time  abdominal  palpation  might  throw  some  light 
on  the  case;  for,  the  uterus  being  tightly  contracted  round  the  h<ad, 
we  might  be  able  to  make  out  its  unusual  dimensions.  The  wasted  and 
shrivelled  appearance  of  the  child's  body,  which  so  often  accompanies 
hydrocephalus,  would  also  arouse  suspicion  as  to  the  cause  of  delay. 
On  the  whole,  such  cases  may  be  fairly  assumed  to  be  less  dangerous  to 
the  mother  than  when  the  head  presents ;  for,  in  the  latter,  the  soft 
parts  are  apt  to  be  subjected  to  prolonged  pressure  and  contusion 
while,  in  the  former,  delay  does  not  commence  till  after  the  shoulders 
are  born,  and  then  the  character  of  the  obstacle  would  be  sooner  dis- 
covered, and  appropriate  means  earlier  taken  to  overcome  it. 

Treatment. — The  treatment  is  simple,  and  consists  in  tapping  the 
head,  so  as  to  allow  the  cranial  bones  to  collapse.  There  is  the  less 
objection  to  this  course,  since  the  disease  almost  necessarily  precludes 
the  hope  of  the  child's  surviving.  The  aspirator  would  draw  oif  the 
fluid  effectually,  and  would  at  least  give  the  child  a  chance  of  life; 
and,  under  certain  circumstances,  the  birth  of  a  child  who  lives  for  a 
short  time  only  may  be  of  extreme  legal  importance.  More  generally 
the  perforator  will  be  used,  and  as  soon  as  it  has  penetrated,  a  gush  of 
fluid  will  at  once  verify  the  diagnosis.  Schroeder  recommends  that, 
after  perforation,  turning  should  be  performed,  on  account  of  the  diffi- 
culty with  which  the  flaccid  head  is  propelled  through  the  pelvis. 
This  seems  a  very  unnecessary  complication  of  an  already  sufficiently 
troublesome  case.  As  a  rule,  when  once  the  fluid  has  been  evacuated, 
the  pains  being  strong,  as  they  generally  are,  no  delay  need  be  appre- 
hended. Should  the  head  not  come  down,  the  cephalotribe  may  be 
Applied,  which  takes  a  firmer  grasp  than  the  forceps,  and  enables  the 
head  to  be  crushed  to  a  very  small  size  and  readily  extracted. 

When  the  breech  presents,  the  head  must  be  perforated  through  the 
occipital  bone,  and  generally  this  may  be  accomplished  behind  the  ear 
without  much  difficulty.  In  a  case  of  Tarnier's  the  vertebral  column 
was  divided  by  a  bistoury  and  an  elastic  male  catheter  introduced  into 
the  vertebral  canal,  through  which  the  intra-cranial  fluid  escaped,  the 
labor  being  terminated  spontaneously.1  •  In  any  case  in  which  it  is 
found  difficult  to  reach  the  skull  with  the  perforator  this  procedure 
should  certainly  be  tried. 

Other  forms  of  dropsical  effusion  may  give  rise  to  some  diffi- 
culty, but  by  no  means  so  serious.  In  a  few  rare  cases  the  thorax  has 

1  Hergott :  Maladies  Foetales  qui  peuvent  faire  obstacle  k  1'accoucheraent.    Paris,  1878. 


390  LABOR. 

been  so  distended  with  fluid  as  to  obstruct  the  passage  of  the  child. 
Ascites  is  somewhat  more  common,  and  occasionally  the  child's  bladder 
is  so  distended  with  urine  as  to  prevent  the  birth  of  the  body.  The 
existence  of  any  of  these  conditions  is  easily  ascertained  ;  for  the  head 
or  breech,  whichever  happens  to  present,  is  delivered  without  difficulty, 
and  then  the  rest  of  the  body  is  arrested.  This  will  naturally  cause 
the  practitioner  to  make  a  careful  exploration,  when  the  cause  of  the 
delay  will  be  detected. 

The  treatment  consists  in  the  evacuation  of  the  fluid  by  puncture. 
In  the  case  of  ascites,  this  should  always  be  done,  if  possible,  by  a 
fine  trocar  or  aspirator,  so  as  not  to  injure  the  child.  This  is  all  the 
more  important  since  it  is  impossible  to  distinguish  a  distended  bladder 
from  ascites,  and  an  opening  of  any  size  into  that  viscus  might  prove 
fatal,  whereas  aspiration  would  do  little  or  no  harm,  and  would  prove 
quite  as  efficacious. 

Foetal  Tumors  Obstructing  Delivery. — Certain  ftetal  tumors  may 
occasion  dystocia,  such  as  malignant  growths,  or  tumors  of  the  kidney, 
liver,  or  spleen.  Cases  of  this  kind  are  recorded  in  most  obstetric 
works.  Hydro  eucephalocele,  or  hydro-rhachitis,  depending  on  defective 
formation  of  the  cranial  or  spinal  bones,  with  the  formation  of  a  large 
protruding  bag  of  fluid,  is  not  very  rare.  The  diagnosis  of  all  such 
cases  is  somewhat  obscure,  nor  is  it  possible  to  lay  down  any  definite 
rules  for  their  management,  which  must  vary  according  to  the  par- 
ticular exigencies.  The  tumors  are  rarely  of  sufficient  size  to  prove 
formidable  obstacles  to  delivery,  and  many  of  them  are  very  com- 
pressible. This  is  specially  the  case  with  the  spiua  bifida  and  similar 
cystic  growths.  Puncture — and,  in  the  more  solid  growths  of  the 
abdomen  or  thorax,  evisceration — may  be  required. 

Other  deformities,  such  as  the  anencephalous  foetus,  or  defective 
development  of  the  thorax  or  abdominal  parietes  with  protrusion  of 
the  viscera,  are  not  likely  to  cause  difficulty ;  but  they  may  much 
embarrass  the  diagnosis  by  the  strange  and  unusual  presentation  that 
is  felt.  If,  in  any  case  of  doubt,  a  full  and  careful  examination  be 
undertaken,  introducing  the  whole  hand  if  necessary,  no  serious  mis- 
take is  likely  to  be  made. 

Dystocia  from  Excessive  Development  of  the  Fcetus. — In 
addition  to  dystocia  from  morbid  conditions  of  the  foetus,  difficulties 
may  arise  from  its  undue  development,  and  especially  from  excessive 
size  and  advanced  ossification  of  the  skull.  This  last  is  especially 
likely  to  cause  delay.  Even  the  slight  difference  in  size  between  the 
male  and  female  head  was  found  by  Simpson  to  have  an  appreciable 
effect  in  increasing  the  difficulty  of  labor,  when  the  statistics  of  a 
large  number  of  cases  were  taken  into  account ;  for  he  proved,  beyond 
doubt,  that  the  difficulties  and  casualties  of  labor  occurred  in  decidedly 
larger  proportion  in  male  than  in  female  births.  Other  circumstances, 
besides  sex  have  an  important  effect  on  the  size  of  the  child.  Thus 
Duncan  and  Hecker  have  shown  that  it  increases  in  proportion  to  the 
age  of  the  mother  and  the  frequency  of  the  labors ;  while  the  size  of 
the  parents  has  no  doubt  also  an  important  bearing  on  the  subject. 

Although  these  influences  modify  the  results  of  labor  en  masse,  they 


DEFORMITIES    OF    THE    PELVIS.  391 

have  little  or  no  practical  bearing  on  any  particular  case,  since  it  is 
impossible  to  estimate  either  the  size  of  the  head  or  the  degree  of  its 
ossification  until  labor  is  advanced. 

Treatment. — When  labor  is  retarded  by  undue  ossification  or  large 
size  of  the  head,  the  case  must  be  treated  on  the  same  general  principles 
which  guide  us  when  the  want  of  proportion  is  caused  by  pelvic  con- 
traction. Hence,  if  delay  arise  which  the  natural  powers  are  insuffi- 
cient to  overcome,  it  will  seldom  happen  that  the  disproportion  is  too 
great  for  the  forceps  to  overcome.  If  we  fail  to  deliver  by  it,  no 
resource  is  left  but  perforation. 

Large  size  of  the  body  of  the  child  is  still  more  rarely  a  cause  of 
difficulty  ;  for,  if  the  head  be  born,  the  compressible  trunk  will  almost 
always  follow.  Still,  a  few  authentic  cases  are  on  record  in  which  it 
was  found  impossible  to  extract  the  foetus  on  account  of  the  unusual 
bulk  of  its  shoulders  and  thorax.  Should  the  body  remain  firmly 
impacted  after  the  birth  of  the  head,  it  is  easy  to  assist  its  delivery  by 
traction  on  the  axilla?,  by  gently  aiding  the  rotation  of  the  shoulders 
into  the  antero-posterior  diameter  of  the  pelvic  cavity,  and,  if  neces- 
sary, by  extracting  the  arms,  so  as  to  lessen  the  bulk  of  the  part  of 
the  body  contained  in  the  pelvis.  Hicks  relates  a  case  in  which 
evisceration  was  required  for  no  other  apparent  reason  than  the 
enormous  size  of  the  body.  The  necessity  for  any  such  extreme 
measure  must,  of  course,  be  of  the  greatest  possible  rarity ;  and  it  is 
quite  exceptional  for  difficulty  from  this  source  to  be  beyond  the 
powers  of  Nature  to  overcome. 


CHAPTER    XII. 

DEFORMITIES   OF   THE  PELVIS. 

Deformities  of  the  Pelvis  form  one  of  the  most  important  subjects 
of  obstetric  study,  for  from  them  arise  some  of  the  gravest  difficulties 
and  dangers  connected  with  parturition.  A  knowledge,  therefore,  of 
their  causes  and  effects,  and  of  the  best  mode  of  detecting  them,  either 
during  or  before  labor,  is  of  paramount  necessity ;  but  the  subject  is 
far  from  easy,  and  it  has  been  rendered  more  difficult  than  need  be, 
from  over-anxiety  on  the  part  of  obstetricians  to  force  all  varieties  of 
pelvic  deformities  within  the  limits  of  their  favorite  classification. 

Difficulties  of  Classification. — Many  attempts  in  this  direction 
have  been  made,  some  of  which  are  based  on  the  causes  on  which  the 
deformities  depend,  others  on  the  particular  kind  of  deformity  pro- 
duced. The  changes  of  form,  however,  are  so  various  and  irregular, 
and  similar,  or  apparently  similar,  causes  so  constantly  produce  dif- 


392  LABOR. 

ferent  effects,  that  all  such  endeavors  have  been  more  or  less  unsuc- 
cessful. For  example,  we  find  that  rickets  (of  all  causes  of  pelvic 
deformity  the  most  important)  generally  produces  a  narrowing  of  the 
conjugate  diameter  of  the  brim ;  while  the  analogous  disease,  osteo- 
malacia,  occurring  in  adult  life,  generally  produces  contraction  of  the 
transverse  diameter,  with  approximation  of  the  pubic  bones,  and  rela- 
tive or  actual  elongation  of  the  conjugate  diameter.  We  might, 
therefore,  be  tempted  to  classify  the  results  of  these  two  diseases  under 
separate  heads,  did  we  not  find  that,  when  rickets  affects  children  who 
are  running  about,  and  subject  to  mechanical  influences  similar  to 
those  acting  upon  patients  suffering  from  osteomalacia,  a  form  of 
pelvis  is  produced  hardly  distinguishable  from  that  met  with  in  the 
latter  disease,  which  by  some  authors  is  described  as  the  pseudo- 
osteomalacic. 

On  the  whole,  therefore,  the  most  simple,  as  well  as  the  most 
scientific,  classification  is  that  which  takes  as  its  basis  the  particular 
seat  and  nature  of  the  deformity.  Let  us  first  glance  at  the  most 
common  causes. 

Causes  of  Pelvic  Deformity. — The  key  to  the  particular  shape 
assumed  by  a  deformed  pelvis  will  be  found  in  a  knowledge  of  the 
circumstances  which  lead  to  its  regular  development  and  normal  shape 
in  a  state  of  health.  The  changes  produced  may,  almost  invariably, 
be  traced  to  the  action  of  the  same  causes  which  produce  a  normal 
pelvis,  but  which,  under  certain  diseased  conditions  of  the  bones  or 
articulations,  induce  a  more  or  less  serious  alteration  in  form.  These 
have  been  already  described  in  discussing  the  normal  anatomy  of  the 
pelvis,  and  it  will  be  remembered  that  they  are  chiefly  the  weight  of 
the  body,  transmitted  to  the  iliac  bones  through  the  sacro-iliac  joints, 
and  counter-pressure  on  these,  acting  through  the  acetabula.  Some- 
times they  act  in  excess  on  bones  which  are  healthy,  but  possibly 
smaller  than  usual,  and  the  result  may  be  the  formation  of  certain 
abnormalities  in  the  size  of  the  various  pelvic  diameters.  At  other 
times  they  operate  on  bones  which  are  softened  and  altered  in  texture 
by  disease,  and  which;  therefore,  yield  to  pressure  far  more  than 
do  healthy  bones. 

Rickets  and  Osteomalacia. — The  two  diseases  which  chiefly  oper- 
ate in  causing  deformity  are  rickets  and  osteomalacia.  Into  the 
essential  nature  and  symptomatology  of  these  complaints  it  would  be 
out  of  place  to  enter  here ;  it  may  suffice  to  remind  the  reader  that 
they  are  believed  to  be  pathologically  similar  diseases,  with  the  im- 
portant practical  distinction  that  the  former  occurs  in  early  life,  before 
the  bones  are  completely  ossified,  and  that  the  latter  is  a  disease  of 
adults,  producing  a  softening  in  bones  that  have  been  hardened  and 
developed.  This  difference  affords  a  ready  explanation  of  the  gener- 
ally resulting  varieties  of  pelvic  deformity. 

Rickets  commences  very  early  in  life,  sometimes,  it  is  believed,  even 
in  utero.  It  rarely  produces  softening  of  the  entire  bones,  and  only 
in  case  of  very  great  severity,  of  those  parts  of  the  bones  that  have 
been  already  ossified.  The  effects  of  the  disease  are  principally 
apparent  in  the  cartilaginous  portions  of  the  bones,  in  which  osseous 


DEFORMITIES    OF    THE    PELVIS.  393 

deposit  has  not  yet  taken  place.  The  bones,  therefore,  are  not  subject 
to  uniform  change,  and  this  fact  has  an  important  influence  in 
determining  their  shape.  Rickety  children  also  have  imperfect  mus- 
cular development ;  they  do  not  run  about  in  the  same  way  as  other 
children,  they  are  often  continuously  in  the  recumbent  or  sitting  pos- 
ture, and  thus  the  weight  of  the  trunk  is  brought  to  bear,  more  than 
in  a  state  of  health,  on  the  softened  bones.  For  the  same  reason 
counter-pressure  through  the  acetabnla  is  absent,  or  comparatively 
slight.  When,  however,  the  disease  occurs  for  the  first  time  in  chil- 
dren who  are  able  to  run  about,  the  latter  comes  into  operation,  and 
modifies  the  amount  and  nature  of  the  deformity.  It  is  to  be  observed 
that  in  rickety  children  the  bones  are  not  only  altered  in  form  from 
pressure,  but  are  also  imperfectly  developed,  and  this  materially 
modifies  the  deformity.  When  ossific  matter  is  deposited,  the  bones 
become  hard  and  cease  to  bend  under  external  influences,  and  retain 
for  ever  the  altered  shape  they  have  assumed. 

Osteomalacia. — In  osteomalacia,  on  the  contrary,  the  already 
hardened  bones  become  softened  uniformly  through  all  their  tex- 
tures, and  thus  the  changes  which  are  impressed  upon  them  are 
much  more  regular  and  more  easily  predicated.  It  is,  however,  an 
infinitely  less  common  cause  of  pelvic  deformity  than  rickets,  as  is 
evidenced  by  the  fact  that  in  the  Paris  Maternity,  in  a  period  of 
sixteen  years,  402  cases  of  deformity  due  to  rickets  occurred  to  one 
due  to  osteomalacia.1 

Their  Varying-  Frequency. — The  frequency  of  both  diseases  varies 
greatly  in  different  countries  and  under  different  circumstances. 
Rickets  is  much  more  common  amongst  the  poor  of  large  cities,  whose 
children  are  ill-fed,  badly-clothed,  kept  in  a  vitiated  atmosphere,  and 
subjected  to  unfavorable  hygienic  conditions.  Deformities  are  there- 
fore more  common  in  them  than  in  the  more  healthy  children  of 
the  upper  classes  or  of  the  rural  population.  The  higher  degrees  of 
deformity,  necessitating  the  Csesarean  section  or  craniotomy,  are  in 
England  of  extreme  rarity  ;  while  in  certain  districts  on  the  Con- 
tinent they  seem  to  be  so  frequent  that  these  ultimate  resources  of  the 
obstetric  art  have  to  be  constantly  employed. 

[Osteomalacia  is  so  rare  in  the  United  States  that  very  few  ob- 
stetricians with  large  experience  have  ever  met  with  a  case ;  and  but 
one  is  on  record  where  the  disease  produced  a  deformity  that  required 
delivery  by  the  abdomen,  and  this  woman  was  not  a  native. 

Rickets  is  becoming  much  more  common  among  the  poor  of  our 
large  cities,  and  especially  in  the  black  race,  in  whom  it  may  be 
readily  recognized  by  their  convex  flattened  tibiae  and  projecting 
heels;  as  also  by  their  peculiar  gait,  which  is  most  marked  in  running. 
The  peculiar  long-flattened  head  of  the  African  foetus  enables  a 
mother  with  a  slightly  deformed  pelvis,  in  many  instances,  either  to 
deliver  herself  or  to  escape  abdomino-uterine  section  by  aid  of  the 
forceps. — ED.] 

In  another  class  of  cases  the  ordinary  shape  is  modified  by  weight 

1  Stanesco :  Recherches  cliniques  sur  les  R6tr£cissements  du  Bassin. 


394  LABOR. 

and  counter-pressure  operating  on  a  pelvis  in  which  one  or  more  of 
the  articulations  is  ossified.  In  this  way  we  have  produced  the 
obliquely  ovate  pelvis  of  Naegele,  or  the  still  more  uncommon  trans- 
versely contracted  pelvis  of  Robert. 

Other  Causes  of  Pelvic  Deformity. — A  certain  number  of  de- 
formed pelves  cannot  be  referred  to  a  modification  of  the  ordinary 
developmental  changes  of  the  bones.  Amongst  these  are  the  deform- 
ities resulting  from  spondylolisthesis,  or  downward  dislocation  of  the 
lower  lumbar  vertebra? ;  from  displacements  of  the  sacrum,  caused  by 
curvatures  of  the  spinal  column,  producing  the  kyphotic  and  scoliotic 
pelves;  or  from  diseases  of  the  pelvic  bones  themselves,  such  as 
tumors,  malignant  growths,  and  the  like. 

The  first  class  of  deformed  pelves  to  be  considered  is  that  in  which 
the  diameters  are  altered  from  the  usual  standard,  without  any  definite 
distortion  of  the  bones ;  and  such  are  often  mere  congenital  variations 
in  size,  for  which  no  definite  explanation  can  be  given.  Of  this  class 
is  the  pelvis  which  is  equally  enlarged  in  all  its  diameters  (pelvis 
cc.quabiliter  justo  major],  which  is  of  no  obstetric  consequence,  except 
inasmuch  as  it  may  lead  to  precipitate  labor,  and  is  not  likely  to  be 
diagnosed  during  life. 

The  corresponding  diminution  of  all  the  pelvic  diameters  (pelvis 
cequabiliter  justo  minor")  may  be  met  with  in  women  who  are  apparently 
well-formed  in  every  respect,  and  whose  external  conformation  and 
previous  history  give  no  indication  of  the  abnormality.  Sometimes 
the  diminution  amounts  to  half  an  inch  or  more,  and  it  can  readily  be 
understood  that  such  a  lessening  in  the  capacity  of  the  pelvis  would 
give  rise  to  serious  difficulty  in  labor.  Thus,  in  three  cases  recorded 
by  Naegele  a  fatal  result  followed ;  in  two  after  difficult  instrumental 
delivery,  and  in  the  third  after  rupture  of  the  uterus.  The  equally 
lessened  pelvis,  however,  is  of  great  rarity.  An  unusually  small  pelvis 
may  be  met  with  in  connection  with  general  small  size,  as  in  dwarfs. 
It  does  not  necessarily  follow,  because  a  woman  is  a  dwarf,  that  the 
pelvis  is  too  small  for  parturition.  On  the  contrary,  many  such 
women  have  borne  children  without  difficulty. 

[We  may  be  greatly  deceived  by  the  external  characteristics  of  a 
large  and  tall  woman  as  to  the  presumed  development  of  her  pelvis, 
and  be  led  to  credit  her  with  diameters  far  beyond  the  actual  measure- 
ments. In  a  lady  above  the  average  height,  witli  large  hips  and  now 
weighing  over  two  hundred  pounds,  I  found  a  vagina  which  the  index 
finger  entered  with  difficulty,  and  with  a  pelvis  so  small  that  it  is 
doubtful  if  she  could  be  delivered  of  a  living  foetus  much  over  seven 
months.  She  bore  one  child  at  maturity,  which  was  delivered  after 
its  death  with  a  crushed  head,  at  the  end  of  three  days'  labor  and  after 
long  and  powerful  traction  by  compressing  forceps.  She  has  a  true 
justo  minor  pelvis. — ED.] 

In  some  cases  a  pelvis  retains  its  infantile  characteristics  after 
puberty  (Fig.  134).  The  normal  development  of  the  pelvis  has  been 
interfered  with,  possibly  from  premature  ossification  of  the  different 
portions  of  the  innominate  bones,  or  from  arrest  of  their  growth  from 
a  weakly  or  rhachitic  constitution.  The  measurements  of  these  pelves 


DEFORMITIES    OF    THE    PELVIS.  395 

are  not  always  below  the  normal  standard ;  they  may  continue  to 
grow,  although  they  have  not  developed.  The  proportionate  measure- 
ments of  the  various  diameters  will  then  be  as  in  the  infant ;  and  the 
antero-posterior  diameter  may  be  longer,  or  as  long  as  the  transverse, 
the  ischia  comparatively  near  each  other,  and  the  pubic  arch  narrow. 
Such  a  form  of  pelvis  will  interfere  with  the  mechanism  of  delivery, 
and  unusual  difficulty  in  labor  will  be  experienced.  Difficulties  from 
a  similar  cause  may  be  expected  in  very  young  girls.  Here,  however, 
there  is  reason  to  hope  that,  as  age  advances,  the  pelvis  will  develop 
and  subsequent  labors  be  more  easy. 


FIG.  134. 


Adult  pelvis  retaining  its  infantile  type. 

The  masculine,  or  funnel-shaped,  pelvis  owes  its  name  to  its  approxi- 
mation to  the  type  of  the  male  pelvis.  The  bones  are  thicker  and 
stouter  than  usual,  the  conjugate  diameter  of  the  brim  longer,  and  the 
whole  cavity  rendered  deeper  and  narrower  at  its  lower  part  by  the 
nearness  of  the  ischial  tuberosities.  It  is  generally  met  with  in  strong 
muscular  women  following  laborious  occupations,  and  Dr.  Barnes, 
from  his  experience  in  the  Royal  Maternity  charity,  says  that  it  chiefly 
occurs  in  weavers  in  the  neighborhood  of  Bethnal  Green,  who  spend 
most  of  their  time  in  the  sitting  posture. 

"  The  cause  of  this  form  of  pelvis  seems  to  be  an  advanced  condition 
of  ossification  in  a  pelvis  which  would  otherwise  have  been  infantile, 
brought  about  by  the  development  of  unusual  muscularity,  correspond- 
ing to  the  laborious  employment  of  the  individual."  The  difficulties  in 
labor  will  naturally  be  met  with  toward  the  outlet,  where  the  funnel 
shape  of  the  cavity  is  most  apparent. 

Diminution  of  the  antero-posterior  diameter  (flattened  pelvis)  is  most 
frequently  limited  to  the  brim,  and  is  by  far  the  most  common  variety 
of  pelvic  deformity.  In  its  slighter  degrees  it  is  not  necessarily  de- 
pendent on  rickets,  although  when  more  marked  it  almost  invariably 
is  so.  When  unconnected  with  rickets  it  probably  can  be  traced  to 
some  injurious  influence  before  the  bones  have  ossified,  such  as  increased 


396 


LABOR. 


pressure  of  the  trunk,  from  carrying  weights  in  early  childhood,  and 
the  like.  By  this  means  the  sacrum  is  unduly  depressed,  and  projects 
forward,  so  as  to  slightly  narrow  the  conjugate  diameter. 

Mode  of  Production  in  Rickets. — AVhen  caused  by  rickets  the 
amount  of  the  contraction  varies  greatly,  sometimes  being  very  slight, 
sometimes  sufficient  to  prevent  the  passage  of  the  child  altogether,  and 
necessitate  craniotomy  or  the  Caesarean  section.  The  sacrum,  softened 
by  the  disease,  is  pressed  vertically  downward  by  the  weight  of  the 
body,  its  descent  being  partially  resisted  by  the  already  ossified  por- 
tions of  the  bone,  so  that  the  result  is  a  downward  and  forward  move- 
ment of  the  promontory.  The  upper  portion  of  the  sacral  cavity  is 


FIG.  135. 


Scolio-rhachitic  pelvis.    (From  a  specimen  in  the  Museum  of  St.  Bartholomew's  Hospital.) 

thus  directed  more  backward  ;  but,  as  the  apex  of  the  bone  is  drawn 
forward  by  the  attachment  of  the  perineal  muscles  to  the  coccyx,  and 
by  the  sacro-ischiatic  ligaments,  a  sharp  curve  of  its  lower  part  in  a 
forward  direction  is  established.  The  horizontal  rami  of  the  pubes 
are  also  flattened,  while  the  ischia  are  more  widely  separated  than  in  a 
normal  pelvis,  thus  producing  a  greater  wridth  of  the  pubic  arch,  while 
the  acetabula  are  turned  forward. 

The  depression  of  the  sacral  promontory  would  tend  to  produce 
strong  traction,  through  the  sacro-iliac  ligaments,  on  the  posterior  end 
of  the  sacro-cotyloid  beams,  and  thus  induce  expansion  of  the  iliac 
bones,  and  consequent  increase  of  the  transverse  diameter  of  the  brim. 
So  an  unusual  length  of  the  transverse  diameter  (T)  is  very  often  de- 
scribed as  accompanying  this  deformity,  but  probably  it  is  not  so  often 
apparent  as  might  otherwise  be  expected,  on  account  of  the  imperfect 
development  of  the  bones  generally  accompanying  rickets ;  and  Barnes l 

1  Lectures  on  Obst.  Operations,  p.  280. 


DEFORMITIES    OF    THE    PELVIS.  397 

says  that  in  parts  of  London  where  deformities  are  most  rife,  any 
enlargement  of  the  transverse  diameter  is  exceedingly  rare. 

Frequently  the  sacrum  is  not  only  depressed,  but  displaced  more  or 
less  to  one  side,  most  generally  to  the  left,  thus  interfering  with  the 
regular  shape  of  the  deformed  brim.  This  is  often  the  result  of 
a  lateral  flexion  of  the  spinal  column,  depending  on  the  rhachitic 
diathesis,  and  when  well  marked  is  known  as  the  scolio-rhachitic  pelvis 
(Fig.  135),  in  which  one  side  of  the  pelvis,  that  corresponding  to  the 
direction  of  the  spinal  curve,  is  asymmetrical  and  contracted,  the  ilio- 
pectineal  line  being  sharply  curved  inward  about  the  site  of  the  sacro- 
iliac  synchoudrosis,  the  symphysis  pubis  being  displaced  toward  the 
opposite  side.  A  somewhat  similar,  but  much  less  marked,  unilateral 
asymmetry  may  exist  in  cases  of  scoliosis  unconnected  with  rickets, 
but  rarely  to  a  sufficient  degree  to  interfere  materially  with  labor. 

In  most  cases  of  this  kind  the  cavity  of  the  pelvis  is  not  diminished 
in  size,  and  is  often  even  more  than  usually  wide.  The  constant 


FIG.  136. 


Rickety  pelvis,  with  backward  depression  of  symphysis  pubis. 

pressure  on  the  ischia,  which  the  sitting  posture  of  the  child  entails, 
tends  to  force  them  apart,  and  also  to  widen  the  pubic  arch.  Con- 
siderable advantage  results  from  this  in  cases  in  which  we  have  to 
perform  obstetric  operations,  as  it  gives  plenty  of  room  for  manipu- 
lation. 

Fignre-of-eight  Deformity. — In  a  few  exceptional  cases  the  nar- 
rowing of  the  conjugate  diameter  is  increased  by  a  backward  depression 
of  the  symphysis  pubis,  which  gives  the  pelvic  brim  a  sort  of  figure- 
of-eight'  shape  (Fig.  136).  The  most  reasonable  explanation  of  this 
peculiarity  seems  to  be  that  it  is  the  result  of  the  muscular  contraction 
of  the  recti  muscles,  at  their  point  of  attachment,  when  the  centre  of 
gravity  of  the  body  is  thrown  backward,  on  account  of  the  projection 
of  the  sacral  promontory.  Sometimes  also  the  antero-posterior  diam- 
eter of  the  cavity  is  unusually  lessened  by  the  disappearance  of  the 
vertical  curvature  of  the  sacrum,  which,  instead  of  forming  a  distinct 
cavity,  is  nearly  flat  (Fig.  137). 

Spondylolisthesis. — In  a  few  rare  cases,  to  which  attention  was 
first  called  in  1853  by  Kilian,  of  Bonn,  a  very  formidable  narrowing 
of  the  conjugate  diameter  of  the  pelvic  brim  is  produced  by  a  down- 
ward displacement  of  the  fourth  and  fifth  lumbar  vertebra,  which 


398 


LABOR. 


become  dislocated  forward,  or,  if  not  actually  dislocated,  at  least  separ- 
ated from  their  several  articulations  to  a  sufficient  extent  to  encroach 
very  seriously  on  the  dimensions  of  the  pelvic  inlet.  This  condition 
is  known  as  spondylolisthesis  (Fig.  138). 


FIG.  137. 


FIG.  138. 


Flatness  of  sacrum,  with  narrowing  of 
pelvic  cavity. 


Pelvis  deformed  by  spondylolisthesis. 
(After  KILIAN.) 


The  effect  of  this  is  sufficiently  obvious,  for  the  projection  of  the 
lumbar  vertebrae  prevents  the  passage  of  the  child.  To  such  an  extent 
is  obstruction  thus  produced,  that,  in  the  majority  of  the  recorded 
cases,  the  Csesarean  section  was  necessary.  The  true  conjugate  diameter, 
that  between  the  promontory  of  the  sacrum  and  the  symphysis  pubis, 
is  increased  rather  than  diminished ;  but,  for  all  practical  purposes, 
the  condition  is  similar  to  extreme  narrowing  of  the  conjugate  from 
rickets,  for  the  bodies  of  the  displaced  vertebra  project  into  and  ob- 
struct the  pelvic  brim. 

The  cause  of  this  deformity  seems  to  be  different  in  different  cases. 
In  some  it  seems  to  have  been  congenital,  and  in  others  to  have  de- 
pended on  some  antecedent  disease  of  the  bones,  such  as  tuberculosis 
or  scrofula,  producing  inflammation  and  softening  of  the  connection 
between  the  ^last  lumbar  vertebra  and  the  sacrum,  thus  permitting 
downward  displacement  of  the  bones.  Lambl  believed  that  it  gener- 
ally followed  spiua  bifida,  which  had  besome  partially  cured,  but 
which  had  produced  deformity  of  the  vertebra?,  and  favored  their  dis- 
location. Brodhurst,1  on  the  other  hand,  thinks  that  it  most  probably 
depends  on  rhachitic  inflammation  and  softening  of  the  osseous  and 
ligamentous  structures,  and  that  it  is  not  a  dislocation  in  the  strict  sense 
of  the  word.  This  condition  has  recently  been  made  the  subject  of 
special  study  by  Dr.  Francois  Neugebauer,2  who  believes  that  the  for- 
ward displacement  is  never  the  result  of  antecedent  disease  of  the 
bones,  but  depends  either  on  congenital  want  of  development  of  the 

1  Obst.  Trans.,  1865,  vol.  vi.  p.  97. 

*  Contribution  k  la  Pathogenic  du  Bassin  vicie  par  le  Glissement  Vertebral.    Paris,  1884. 


DEFORMITIES    OF    THE    PELVIS. 


399 


[FIG.  139. 


vertebral  arches,  or  on  traumatism,  such  as  fracture  of  the  articular 
processes,  which  allows  the  weight  of  the  trunk  to  displace  the  body  of 
the  last  lumbar  vertebra  forward,  either  partially  or  entirely. 

[We  are  indebted  to  Kilian,  of  Bonn,  Germany,  for  the  first  careful 
investigation  of  the  true  character  of  spondylolisthetic  deformity, 
although  the  credit  of  initial  men- 
tion is  due  to  Rokitansky,  of 
Austria,  who  wrote  in  1839,  ante- 
dating the  monograph  of  the 
former  (1853)  by  fourteen  years. 
No  special  mention  is  made  of 
this  peculiar  lordosis  by  Roki- 
tansky in  his  Manual  of  Patho- 
logical Anatomy  in  1844,  but  in 
his  Lehrbuch  (1855)  it  is  given, 
with  due  credit  to  Kilian.  Dur- 
ing the  thirty-three  years  that 
have  passed  since  Kilian  prepared 
his  paper  from  observations  made 
upon  three  pelves  which  had  been 
obtained  from  subjects  in  whom 
the  Caesarean  section  had  proved 
fatal,  one  of  them  after  a  second 
operation,  there  have  appeared 
numerous  monographs  and  de- 
scriptions of  cases,  much  the  most 
valuable  and  extensive  of  which  are  those  by  Dr.  Franz  Ludwig 
Ncugebauer,  of  Warsaw,  and  Dr.  A.  Swedelin,  of  St.  Petersburg,  the 
latter  of  whom  furnishes  the  bibliography  of  the  subject.  These 
valuable  papers  cover  223  and  40  pages  respectively  of  the  Arehiv  fur 
Gyndkologie,  Berlin,  vols.  xix.,  xx.,  xxi.,  xxii.,  and  xxv.,  for  1882-85. 

The  most  frequent  origin  of  spondylolisthetic  deformity  appears  to 
lie  in  an  incomplete  ossification  of  the  last  lumbar  vertebra,  whereby 
its  anterior  and  posterior  portions  are  rendered  liable  to  separate  under 
the  superincumbent  weight  of  the  body.  Hence  the  subjects  of  the 
slipping  are  frequently  stout,  heavy  women.  This  was  markedly  the 
case  in  the  woman  who  came  under  the  care  of  Prof.  James  Blake,  of 
San  Francisco.1  This  patient  was  married  at  fifteen  years  of  age,  at 
which  time  she  weighed  101  pounds,  but  increased  to  199  pounds  by 
the  time  her  first  child  was  born.  Her  first  and  second  labors  were 
tedious,  but  the  children  were  born  alive  ;  she  aborted  of  another  foetus 
at  four  months,  and  later  was  delivered  at  maturity  of  four  others,  all 
dead,  the  conjugate  space  in  the  seventh  labor  being  computed  at  three 
and  a  half  inches.  This  labor  was  so  difficult  that  it  Avas  decided,  in 
the  event  of  another  pregnancy,  to  bring  on  labor  prematurely.  She 
became  pregnant  for  the  eighth  time  at  the  age  of  twenty-six,  when 
she  weighed  220  pounds.  Labor  was  induced  in  the  seventh  month, 
but  the  foetus  was  lost,  as  it  weighed  nearly  six  pounds  and  the  lurnbo- 


Spondylolisthesis.    (After  NEUGEBAUER.)] 


Pac.  Med.  and  Surg.  Journ.,  Feb.  1867.] 


400  LABOR. 

pubic  space  was  reduced  to  three  inches.  This  woman  is  said  to  have 
undergone  the  change  in  her  vertebrae  without  pain  or  sign  of  ill- 
health,  and  to  have  retained  a  remarkable  activity  for  her  weight. 
After  her  eighth  delivery  she  was  up  in  six  days  and  downstairs  in 
ten.  The  history  of  this  case  would  indicate  that  the  deforming  pro- 
cess must  have  been  slowly  progressing  during  more  than  ten  years. 

In  contrast  with  this  painless  case  in  a  multipara  we  have  the  oppo- 
site in  a  nullipara,  reported  by  Dr.  Olshausen,  formerly  of  Halle. 
The  disease  commenced  in  his  patient  when  a  girl  of  eighteen,  with 
severe  pains  in  the  sacrum  and  hips,  as  in  nialacosteon.  She  had  not 
had  rickets  in  childhood,  had  enjoyed  good  health  up  to  this  time,  and 
was  quite  straight.  As  her  disease  progressed  she  found  on  awaking 
one  morning  that  she  could  not  straighten  her  spine,  and  was  forced 
to  walk  with  her  body  bent  forward.  She  was  put  under  medical 
treatment  at  the  surgical  clinic ;  had  no  fever,  and  in  time  ceased  to 
suffer,  and  was  discharged.  Becoming  pregnant  at  the  age  of  twenty- 
four,  Dr.  Olshauseu  delivered  her  in  1863  by  the  Caesarean  section ; 
the  child  lived,  but  she  was  lost  on  the  fourth  day  by  peritonitis. 
The  lumbo-pubic  diameter  was  found  to  measure  three  inches,  and  the 
line  of  the  conjugate  struck  the  lower  margin  of  the  third  lumbar 
vertebra. 

Spondylolisthesis  is  of  very  great  rarity  in  our  country — so  much  so 
that  I  know  of  but  one  case  delivered  under  the  Conservative  Caesarean 
section ;  this  was  performed  by  Dr.  Hal  C.  AVyman,  at  Detroit,  on 
January  19,  1891,  the  woman  having  been  in  labor  three  days.  The 
child  was  lost,  and  the  mother  died  in  forty-eight  hours,  of  pulmonary 
oedema  and  cyanosis. — ED.] 

Spondylolizema. — A  somewhat  analogous  deformity  has  been 
described  by  Hergott1  under  the  name  of  Spondylolizema.  In  this  the 
bodies  of  the  lower  lumbar  vertebrae  having  been  destroyed  by  caries, 
the  upper  lumbar  vertebrae  sink  downward  and  forward,  so  as  to 
obstruct  the  pelvic  inlet  and  prevent  the  engagement  of  the  foetus. 
It  thus  differs  from  Spondylolisthesis,  in  which  there  is  dislocation, 
but  not  destruction,  of  the  bodies  of  the  lower  lumbar  vertebrae. 

Deformity  from  Osteomalacia. — The  most  marked  examples  of 
narrowing  of  both  oblique  diameters  depend  on  osteomalacia,  In  this 
disease,  as  has  already  been  remarked,  the  bones  are  uniformly  softened, 
and  the  alterations  in  form  are  further  influenced  by  the  fact  that  the 
disease  commences  after  union  of  the  separate  portions  of  the  ossa 
innominata,  has  been  completely  effected.  The  amount  of  deformity 
in  the  worst  cases  is  very  great,  and  frequently  renders  delivery  im- 
possible without  the  Caesarean  section.  Sometimes  the  softening  of 
the  bones  proves  of  service  in  delivery  by  admitting  of  the  dilatation 
of  the  contracted  pelvic  diameter  by  the  pressure  of  the  presenting 
part,  or  even  by  the  hand.  Some  curious  cases  are  on  record  in  which 
the  deformity  was  so  great  as  to  apparently  require  the  Caesarean  sec- 
tion, but  in  which  the  softened  bones  eventually  yielded  sufficiently  to 
render  this  unnecessary. 

1  Arch,  de  Tocologie,  1877,  p.  65. 


DEFORMITIES    OF    THE    PELVIS.  401 

The  weight  of  the  body  depresses  the  sacrum  in  a  vertical  direction, 
and  at  the  same  time  compresses  its  component  parts  together,  so  as  to 
approximate  the  base  and  apex  of  the  bone,  and  narrow  the  conjugate 
diameter  of  the  brim,  by  causing  the  promontory  to  encroach  upon  it. 

FIG.  140. 


Osteomalacic  pelvis. 


The  most  characteristic  changes  are  produced  by  the  pushing  inward 
of  the  walls  of  the  pelvis  at  the  cotyloid  cavities,  in  consequence  of 
pressure  exerted  at  these  points  through  the  femora.  The  effect  of  this 
is  to  diminish  both  oblique  diameters,  giving  the  brim  somewhat  the 
shape  of  a  trefoil,  or  an  ace  of  clubs.  The  sides  of  the  pubes  are  at 


FIG.  141. 


Extreme  degree  of  osteomalacic  deformity. 

the  same  time  approximated,  and  may  become  almost  parallel,  and  the 
true  conjugate  may  be  even  lengthened  (Fig.  140).  The  tuberosities 
of  the  ischia  are  also  compressed  together,  with  the  rest  of  the  lateral 
pelvic  wall,  so  that  the  outlet  is  greatly  deformed  as  well  as  the  brim. 
(Fig.  141). 

Obliquely  Contracted  Pelvis. — That  form  of  deformity  in  which 
one  oblique  diameter  only  is  lessened  has  received  considerable  atten- 

26 


402  LABOR. 

tion,  from  having  been  made  the  subject  of  special  study  by  Naegele, 
and  is  generally  known  as  the  obliquely  contracted  pelvis  (Fig.  142).  It 
is  a  condition  that  is  very  rarely  met  with,  although  it  is  interesting 
from  an  obstetric  point  of  view,  as  throwing  considerable  light  on  the 
mode  in  which  the  natural  development  of  the  pelvis  is  eifected.  It  is 
difficult  to  diagnose,  inasmuch  as  there  is  no  apparent  external  de- 
formity, and  probably  it  has  never,  in  fact,  been  detected  before 
delivery.  It  has  a  very  serious  influence  on  labor  ;  Litzmann  found 
that  out  of  twenty-eight  cases  of  this  deformity,  twenty-two  died  in 
their  labors,  and  five  more  in  subsequent  deliveries.  The  prognosis, 
therefore,  is  very  formidable,  and  renders  a  knowledge  of  this  distor- 
tion, rare  though  it  be,  of  importance. 

Its  essential  characteristic  is  flattening  and  want  of  development  of 
one  side  of  the  pelvis,  associated  with  ankylosis  of  the  corresponding 

sacro-iliac  synchondrosis.     The  latter 
FIG.  142.  is   probably   always   present,   and   it 

seems  to  be  most  generally  a  con- 
genital malformation.  The  lateral 
half  of  the  sacrum  on  the  same  side, 
and  the  entire  innominate  bone,  are 
much  atrophied.  The  promontory  of 
the  sacrum  is  directed  toward  the 
diseased  side,  and  the  symphysis  pubis 
is  pushed  over  toward  the  healthy 
side.['] 

The  main  agent  in  the  production 
of -this  deformity  is  the  absence  of  the 

Obliquely  contracted  pelvis.    (After  .,.         .    .    /        ,  .  ,  ., 

DUNCAN.)  sacro-iliac  joint,  which  prevents  the 

proper  lateral  expansion  of  the  pelvic 

brim  on  that  side,  and  allows  the  counter-pressure  through  the  femur 
to  push  in  the  atrophied  os  innominatum  to  a  much  greater  extent  than 
usual.  The  chief  diminution  in  the  length  of  the  pelvic  diameter  is 
between  the  ilio-pectineal  eminence  of  the  affected  side  and  the  healthy 
sacro-iliac  joint;  while  the  oblique  diameter  between  the  ankylosed 
joint  and  the  healthy  os  innominatum  is  of  normal  length. 

[Coxalgia  in  little  girls,  affecting  one  joint,  not  only  stunts  the 
growth  of  the  lower  extremity,  but  that  of  the  ilium  as  well,  making  the 
superior  strait  D-shaped ;  the  linea  ilio-pedinea  having  but  little  curve 
on  the  ankylosed  side.  Such  cases  have  several  times  required 
Csesarean  delivery  in  this  country. — ED.] 

Narrowing  of  the  Transverse  Diameter. — Transverse  contraction 
of  the  pelvic  brim  is  very  much  less  common  than  narrowing  of  the 
conjugate  diameter.  It  most  frequently  depends  on  backward  curvature 
of  the  lower  parts  of  the  spinal  column,  in  consequence  of  disease  of 
the  vertebrae.  This  form  of  deformed  pelvis  is  generally  known  as 
the  kyphotic  (Fig.  143).  The  effect  of  the  spinal  curvature  is  to  drag 
the  promontory  of  the  sacrum  backward,  so  that  it  is  high  up  and  out 
of  reach.  By  this  means  the  antero-posterior  diameter  of  the  brim  is 

[l  It  was  for  this  form  of  pelvis  that  Pinard,  of  Paris,  performed,  with  success,  the  operation  of 
unilateral  pubio-ischiotomy.— ED.] 


DEFORMITIES    OF    THE    PELVIS. 


403 


increased,  while  the  transverse  is  lessened;  the  relative  proportion 
between  the  two  is  thus  reversed.  While  the  upper  portion  of  the 
sacrum  is  displaced  backward,  its  lower  end  is  projected  forward,  so 


FIG.  143. 


Kyphotic  pelvis.    (From  a  specimen  in  the  Museum  of  St.  Bartholomew's  Hospital.) 

that  the  antero-posterior  diameters  of  the  cavity  and  outlet  are  con- 
siderably diminished.  The  ischial  tuberosities  are  also  nearer  to  each 
other,  and  the  pubic  arch  is  narrowed.  Obstruction  to  delivery  will 
be  chiefly  met  with  at  the  lower  parts 
and  outlet  of  the  pelvic  cavity ; 
for,  although  the  transverse  diam- 
eter of  the  brim  is  narrowed,  there 
is  generally  sufficient  space  for  the 
passage  of  the  head. 

Robert's  Pelvis. — Another  form 
of  transversely  contracted  pelvis  is 
known  as  Robert's  pelvis  (Fig.  144), 
having  been  first  discovered  by 
Robert,  of  Coblentz.  It  is  in  fact  a 
double  obliquely  contracted  pelvis, 
depending  on  ankylosis  of  both 
sacro-iliac  joints,  and  consequent  de- 
fective development  of  the  innomi- 
nate bones.  The  shape  of  the  pelvic  brim  is  markedly  oblong,  and 
the  sides  of  the  pelvis  are  more  or  less  parallel  with  each  other.  The 


Robert's,  or  double  obliquely  contracted 
pelvis.    (After  DUNCAN.) 


404 


LABOR. 


FIG.  145. 


outlet  is  also  much  contracted  transversely.  The  amount  of  obstruc- 
tion is  very  great,  so  that,  according  to  Schroeder,  out  of  seven  well- 
authenticated  cases,  the  Csesarean  section  was  required  in  six. 

Deformity  from  Old-standing-  Hip-joint  Disease. — Another  cause 
of  transverse  deformity  occasionally  met  with  is  luxation  of  the  head 
of  the  femur,  depending  on  old-standing  joint  disease.  The  head  of 
the  femur,  in  this  case,  presses  on  the  innominate  bone  at  the  site  of 
dislocation,  and  the  result  is  that  the  iliac  fossa  on  the  affected  side,  or 
both  if  the  accident  happens  on  both  sides,  is  pushed  inward,  the 
transverse  diameter  of  the  brim  being  lessened.  The  tuberosity  of 
the  ischium  is,  ho  ver,  projected  outward,  so  that  the  outlet  of  the 
pelvis  is  increased  rather  than  diminished. 

Deformity  from  Tumors,  Fractures,  etc. — Obstruction  of  the 
pelvic  cavity  from  exostoses  or  other  forms  of  tumors  growing  from 
the  bones  is  of  great  rarity  (Fig.  145).  It  may,  however,  produce 
very  serious  dystocia.  Several  curious  examples  are  collected  in  Mr. 

Wood's  article  on  the  pelvis,  in  some 
of  which  the  obstruction  was  so  great 
as  to  necessitate  the  Csesarcan  section. 
Some  of  these  growths  were  true 
exostoses,  and  according  to  Stad- 
feldt,1  these  are  commonly  found  in 
pelves  that  are  otherwise  contracted ; 
others,  osteo-sarcomatous  tumors  at- 
tached to  the  pelvic  bones,  most 
generally  the  upper  part  of  the 
sacrum ;  and  others  were  malignant. 
In  some  cases  spiculse  of  bone  have 
developed  about  the  linea  ilio-pec- 
tinea  or  other  parts  of  the  pelvis, 
which  may  not  be  sufficient  to  pro- 
duce obstruction,  but  which  may 
injure  the  uterus,  or  even  the  foetal 
head,  when  they  are  pressed  upon 
them.  Irregular  projections  may 
also  arise  from  the  callus  of  old 
fractures  of  the  pelvic  bones.  All 

such  cases  defy  classification  and  differ  so  greatly  in  their  extent,  and 
in  their  effect  on  labor,  that  no  rules  can  be  laid  down  for  them,  and 
each  must  be  treated  on  its  own  merits. 

The  effects  of  pelvic  contractions  on  labor  vary,  of  course, 
greatly  with  the  amount  and  nature  of  the  deformity ;  but  they  must 
always  give  rise  to  anxiety,  and  in  the  graver  degrees  they  produce 
the  most  serious  difficulties  we  have  to  contend  with  in  the  whole 
range  of  obstetrics. 

In  the  lesser  degrees,  in  which  the  proportion  between  the  present- 
ing part  and  the  pelvis  is  only  slightly  altered,  we  may  observe  little 
abnormal  beyond  a  greater  intensity  of  the  pains,  and  some  protraction 


Bony  growth  from  sacrum  obstructing  the 
pelvic  cavity. 


1  Obst.  Journ.,  1879-80,  vol.  vii.  p.  201. 


DEFORMITIES    OF    THE    PELVIS.  405 

of  the  labor.  It  is  generally  observed  that  the  uterine  contractions 
are  strong  and  forcible  in  cases  of  this  kind,  probably  because  of  the 
increased  resistance  they  have  to  contend  against ;  and  this  is  obviously 
a  desirable  and  conservative  occurrence,  which  may,  of  itself,  suffice 
to  overcome  the  difficulty.  The  first  stage,  however,  is  not  unfre- 
quently  prolonged,  and  the  pains  are  ineffective,  for  the  head  does  not 
readily  engage  in  the  brim,  the  uterus  is  more  mobile  than  in  ordinary 
labors,  and  it  probably  acts  at  a  disadvantage. 

Bisk  to  the  Mother. — In  the  more  serious  cases,  the  mother  is 
subjected  to  many  risks,  directly  proportionate  to  the  amount  of 
obstruction  and  the  length  of  the  labor.  The  long-continued  and 
excessive  uterine  action,  produced  by*  the  vain  endeavors  to  push  the 
child  through  the  contracted  pelvic  canal,  the  more  or  less  prolonged 
contusion  and  injury  to  which  the  maternal  soft  parts  are  necessarily 
subjected  (not  unfrequently  ending  in  inflammation  and  sloughing 
with  all  its  attendant  dangers),  and  the  direct  injury  which  may  be 
inflicted  by  the  measures  we  are  compelled  to  adopt  for  aiding  delivery 
(such  as  the  forceps,  turning,  craniotomy,  or  Caesarean  section),  all 
tend  to  make  the  prognosis  a  matter  of  grave  anxiety.  [The  Csesarean 
operation  has  been  performed  ten  times  in  the  United  States  in  cases 
of  pelvic  exostosis,  with  five  recoveries.  One  woman  was  operated 
upon  three  times  and  died  from  the  third  operation ;  five  of  the  ten 
children  were  saved.  Of  the  fatal  cases,  three  were  in  labor  three 
days ;  one,  two  days ;  in  one,  labor  was  induced ;  and  one  had  been  in 
convulsions  for  twenty-four  hours.  Of  the  five  that  recovered,  two 
were  in  labor  "  a  few  hours ;"  one,  twelve  hours ;  one,  twenty-four 
hours  ;  and  one,  thirty-eight  hours. — ED.] 

Risk  to  the  Child. — Nor  are  the  dangers  less  to  the  child ;  and  a 
very  large  proportion  of  stillbirths  will  always  be  met  with.  The 
infantile  mortality  may  be  traced  to  a  variety  of  causes,  the  most 
important  being  the  protraction  of  the  labor,  and  the  continuous 
pressure  to  which  the  presenting  part  is  subjected.  For  this,  reason, 
even  in  cases  in  which  the  contraction  is  so  slight  that  the  labor  is 
terminated  by  the  natural  powers,  it  has  been  estimated  that  one  out 
of  every  five  children  is  stillborn  ;  and  as  the  deformity  increases  in 
amount,  so,  of  course,  does  the  prognosis  to  the  child  become  more 
unfavorable. 

Prolapse  of  the  umbilical  cord  is  of  very  frequent  occurrence 
in  cases  of  pelvic  deformity,  the  tendency  to  this  accident  being  trace- 
able to  the  fact  of  the  head  not  entering  and  occupying  the  upper 
strait  of  the  pelvis  as  in  ordinary  labors,  and  thus  leaving  a  space 
through  which  the  cord  may  descend.  So  frequently  is  this  compli- 
cation met  with  in  pelvic  deformity  that  Stanesco  found  it  had 
happened  as  often  as  fifty-nine  times  in  414  labors;  and  when  the 
dangers  of  prolapsed  funis  are  added  to  those  of  protracted  labors,  it 
is  hardly  a  matter  of  surprise  that  the  occurrence  should,  under  such 
circumstances,  almost  always  prove  fatal  to  .the  child. 

The  head  of  the  child  is'also  liable  to  injury  of  a  more  or  less  grave 
character,  from  the  compression  to  which  it  is  subjected,  especially  by 
the  promontory  of  the  sacrum.  Independently  of  the  transient  effects 


406  LABOR. 

of  undue  pressure  (temporary  alteration  of  the  shape  of  the  bones 
and  bruising  of  the  scalp),  there  is  often  met  with  a  more  serious 
depression  of  the  bones  of  the  skull,  produced  by  the  sacral  promon- 
tory. This  is  most  marked  in  cases  in  which  the  head  has  been 
forcibly  dragged  past  the  projecting  bone  by  the  forceps,  or  after 
turning.  The  amount  of  depression  varies  with  the  degree  of  con- 
traction ;  but  sometimes,  were  it  not  for  the  yielding  of  the  bones  of 
the  foetal  skull  in  this  way,  delivery,  without  lessening  the  size  of  the 
head  by  perforation,  would  be  impossible.  Such  depressions  are  found 
at  the  spot  immediately  opposite  the  promontory,  generally  at  the  side 
of  the  skull  near  the  junction  of  the  frontal  and  parietal  bones. 
Sometimes  there  is  a  slight  permanent  mark,  but  more  often  the 
depression  disappears  in  a  few  days.  The  prognosis  to  the  child  is, 
however,  grave,  when  the  contraction  has  been  sufficient  to  indent  the 
skull ;  for  it  has  been  found  that  50  per  cent,  of  the  children  thus 
marked  died  either  immediately  or  shortly  after  labor.1 

Course  of  Labor. — The  means  which  Nature  takes  to  overcome 
these  difficulties  are  well  worthy  of  study,  and  there  are  certain  pecu- 
liarities in  the  mechanism  of  delivery,  when  pelvic  deformities  exist, 
which  it  is  of  importance  to  understand,  as  they  guide  us  in  deter- 
mining the  proper  treatment  to  adopt. 

Frequency  of  Malpresentation. — Malpresentations  of  the  foetus 
are  of  much  more  frequent  occurrence  than  in  ordinary  labors ;  partly 
because  the  head  does  not  engage  readily  in  the  brim,  but,  remaining 
free  above  it,  is  apt  to  be  pushed  away  by  the  uterine  contractions,  and 
partly  because  of  the  frequent  alteration  of  the  axis  of  the  uterine 
tumor.  The  pendulous  condition  of  the  abdomen  in  cases  of  pelvic 
deformity  is  often  very  obvious,  so  that  the  fundus  is  sometimes 
almost  in  a  line  with  the  cervix,  and  thus  transverse  or  other  abnormal 
positions  are  very  frequently  met  with.  It  is  to  be  noted,  however, 
that  we  cannot  regard  breech  presentations  as  so  unfavorable  as  in 
ordinary  labors,  for  the  pressure  from  the  contracted  pelvis  is  less 
likely  to  be  injurious  when  applied  to  the  body  than  to  the  head  of 
the  child ;  and,  indeed,  as  we  shall  presently  see,  the  artificial  pro- 
duction of  these  presentations  is  often  advisable  as  a  matter  of  choice. 

Mechanism  of  Delivery  in  Head  Presentations. — The  mode  in 
which  the  head  passes  naturally  through  a  contracted  pelvis  is  in  some 
respects  different  from  the  ordinary  mechanism  of  delivery  in  head 
presentations,  and  has  been  carefully  worked  out  by  Spiegelberg  and 
other  German  obstetricians. 

The  means  which  Nature  adopts  to  overcome  the  difficulty  are 
different  in  cases  in  which  there  is  a  marked  narrowing  of  the  con- 
jugate diameter  of  the  brim,  and  in  those  in  which  there  is  a  generally 
contracted  pelvis. 

a.  In  Contracted  Brim. — In  the  former,  and  more  common,  de- 
formity, the  head  lies  at  the  brim  with  its  long  occipito-frontal  diameter 
in  the  transverse  diameter  of  the  pelvis,  and,  as  both  parietal  bones 
cannot  enter  the  contracted  brim,  it  lies  with  one  parietal  bone  on 

1  Schroeder,  op.  cit..  p.  256. 


DEFORMITIES    OF    THE    PELVIS. 


407 


FIG.  146. 


Head  passing  through  the  inlet  in 
a  flat  pelvis.    (After  TARVIN.) 


a  much  lower  level  than  the  other;  in  the  large  majority  of  cases 
that  nearest  the  pubes  being  most  depressed,  so  that  the  sagittal  suture 
is  felt  high  up  near  the  promontory  of  the  sacrum  (Fig.  146).  As 
labor  advances,  if  the  contraction  is  not  too 
great  to  be  insuperable,  the  anterior  fonta- 
nelle comes  much  more  within  reacli  than 
in  ordinary  labor,  while,  at  the  same  time, 
the  occipital  portion  of  the  head  is  shoved 
to  the  side  of  the  pelvis,  so  that  its  narrow 
bi-temporal  diameter  engages  in  the  con- 
tracted conjugate.  At  this  stage,  on  exami- 
nation, it  will  be  found — supposing  we  have 
to  do  with  a  case  in  which  the  occiput  points 
to  the  left  side  of  the  pelvis — that  the 
anterior  fontanelle  is  lower  than  the  pos- 
terior, and  to  the  right,  that  the  bi-temporal 
diameter  of  the  head  is  engaged  in  the  con- 
jugate diameter  of  the  brim  (as  the  smallest 
diameter  of  the  skull,  there  is  manifest 
advantage  in  this),  and  that  the  bi- parietal 
diameter  and  the  largest  portion  of  the  head 
points  to  the  left  side.  The  sagittal  suture 

will  be  felt  running  across  in  the  transverse  diameter  of  the  brim,  but 
nearer  to  the  sacrum,  the  head  being  placed  obliquely.  As  the  head 
is  forced  down  by  the  uterine  contractions,  the  parietal  bone,  which  is 
resting  on  the  promontory,  is  pushed  against  it,  so  that  the  sagittal 
suture  is  forced  more  into  the  true  transverse  diameter  of  the  pelvic 
brim,  and  approaches  nearer  to  the  pubes.  The  next  step  is  the 
depression  of  the  head,  the  occiput  undergoing  a  sort  of  rotation  on 
its  transverse  axis  so  that  it  reaches  a  plane  below  the  brim.  When 
this  is  accomplished,  the  rest  of  the  head  readily  passes  the  obstruction. 
The  forehead  now  meets  with  the  resistance  of  the  pelvic  walls,  the 
posterior  fontanelle  descends  to  a  loMrer  level, 
and,  as  the  cavity  of  the  pelvis  in  cases  of 
antero-posterior  contraction  of  the  brim  is 
generally  of  normal  dimensions,  the  rest  of 
the  labor  is  terminated  in  the  usual  way. 

b.  In  Generally  Contracted  Pelvis. — In 
the  generally  contracted  pelvis  the  head  enters 
the  brim  with  the  posterior  fontanelle  lowest, 
and  it  is  after  it  has  engaged  in  it  that  the 
re- i stance  to  its  progress  becomes  manifest. 
The  result  is,  therefore,  an  exaggeration  of 
what  is  met  with  in  ordinary  cases.  The 
resistance  to  the  anterior  or  longer  arm  of 
the  lever  is  greater  than  that  to  the  occipital 
or  shorter ;  and,  therefore,  the  flexion  of 
the  head  becomes  very  marked  (Fig.  147). 
The  posterior  fontaneile  is  consequently  unusually  depressed,  and  the 
anterior  quite  out  of  reach.  So  the  head  is  forced  down  as  a  wedge, 


FIG.  147. 


Marked  flexion  of  the  head 
entering  a  generally  contracted 
pelvis.  (After  PAKVIN.) 


408  LABOR. 

and  its  further  progress  must  depend  upon  the  amount  of  contraction. 
If  this  be  not  too  great  the  anterior  fontanelle  eventually  descends, 
and  delivery  is  completed  in  the  usual  way.  Should  the  contraction 
be  too  much  to  permit  of  this,  the  head  becomes  jammed  in  the  pelvis, 
and  diminution  of  its  size  may  be  essential. 

In  cases  of  deformity  of  the  conjugate  diameter  combined  with 
general  contraction  of  the  pelvis,  the  mechanism  partakes  of  the  pecu- 
liarities of  both  these  classes,  to  a  greater  or  less  extent,  in  proportion 
to  the  preponderance  of  one  or  other  species  of  deformity. 

Diagnosis. — It  rarely  happens  that  deformities  of  the  pelvis,  except 
of  the  gravest  kind,  are  suspected  before  labor  has  actually  commenced, 
and  therefore  we  are  not  often  called  upon  to  give  an  opinion  as  to 
the  condition  of  the  pelvis  before  delivery.  Should  we  be  so,  there  • 
are  various  circumstances  which  may  aid  us  in  arriving  at  a  correct 
conclusion.  Prominent  among  them  is  the  history  of  the  patient  in 
childhood.  If  she  is  known  to  have  suffered  from  rickets  in  early 
life,  more  especially  if  the  disease  has  left  evident  traces  in  deformities 
of  the  limbs,  or  in  a  dwarfed  and  stunted  growth,  or  in  curvature  of 
the  spine,  there  will  be  strong  presumptive  evidence  of  pelvic  deformity; 
a  markedly  pendulous  state  of  the  abdomen  may  also  tend  to  confirm 
the  suspicion.  Nothing  short  of  a  careful  examination  of  the  pelvis 
itself  will,  however,  clear  up  the  point  with  certainty ;  and  even  by 
this  means,  to  estimate  the  precise  degree  of  deformity  with  accuracy 
requires  considerable  skill  and  practice.  The  ingenuity  of  practitioners 
has  been  much  exercised — it  might  perhaps  be  justly  said  wasted — in 
the  invention  of  various  more  or  less  complicated  pelvimeters  for  aid- 
ing us  in  obtaining  the  desired  object.  It  is,  however,  pretty  generally 
admitted  by  all  accoucheurs  that  the  hand  forms  the  best  and  most 
reliable  instrument  for  this  purpose,  at  any  rate  as  regards  the  interior 
of  the  pelvis ;  although  a  pair  of  callipers,  such  as  Baudelocque's  well- 
known  instrument,  is  essential  for  accurately  determining  the  external 
measurements.  The  objections  to  all  internal  pelvimeters,  even  those 
most  simple  in  their  construction,  are  their  cost  and  complexity,  and 
the  impossibility  of  using  them  without  pain  or  injury  to  the  patient. 

It  was  formerly  thought  that  by  measuring  the  distance  between  the 
spinous  processes  of  the  sacrum  and  the  symphysis  pubis,  and  sub- 
tracting from  it  what  we  judge  to  be  the  thickness  of  the  bones  and 
soft  parts,  we  might  arrive  at  an  approximate  estimate  of  the  measure- 
ment of  the  conjugate  diameter  of  the  pelvic  brim.  It  is  now  admitted 
that  this  method  can  never  be  depended  on,  and  that,  taken  by  itself, 
it  is  practically  useless.  A  change  in  the  relative  length  of  other  ex- 
ternal measurements  of  the  pelvis  is,  however,  often  of  great  value  in 
showing  the  existence  of  deformity  internally,  although  not  in  judging 
of  its  amount.  The  measurements  which  are  used  for  this  purpose  are 
between  the  anterior  superior  spines  of  the  ilia,  and  between  the  centres 
of  their  crests,  averaging  respectively  ten  and  one-quarter  and  eleven 
and  one-quarter  inches  in  the  covered  pelvis.  According  to  Spiegel- 
berg,  these  measurements  may  give  one  of  three  results. 

.  Both  may  be  less  than  they  ought  to  be,  but  the  relation  of  one 
to  the  other  remains  unchanged. 


DEFORMITIES    OF    THE    PELVIS.  409 

2.  That  between  the  crests  is  not,  or  is  at  most  very  little,  dimin- 
ished, but  that  between  the  spines  is  increased. 

3.  Both  are  diminished,  but  at  the  same  time  their  mutual  relation  is 
not  normal,  the  distance  between  the  spines  being  as  long,  if  not  longer, 
than  that  between  the  crests. 

No.  1  denotes  a  uniformly  contracted  pelvis ;  No.  2,  a  pelvis  simply 
contracted  in  the  conjugate  diameter  of  the  brim,  and  not  otherwise 
deformed;  No.  3,  a  pelvis  with  narrowed  conjugate  and  also  uniformly 
contracted,  as  in  the  severe  type  of  rhachitic  deformity.  If,  however, 
both  these  measurements  are  of  average  length,  and  the  distance  be- 
tween the  crests  is  about  one  inch  greater  than  between  the  spines,  the 
pelvis  is  normal. 

Besides  the  above,  useful  information  may  be  obtained  by  the  meas- 
urement of  the  external  conjugate  diameter,  which  averages  seven  and 
three-quarters  inches,  varying  somewhat  with  the  amount  of  adipose 
tissue  present.  This  may  be  taken  by  placing  one  point  of  the  callipers 
in  the  depression  below  the  spine  of  the  last  lumbar  vertebra,  the  other 
at  the  centre  of  the  upper  edge  of  the  symphysis  pubis.  If  the  meas- 
urement be  distinctly  below  the  average,  not  more,  for  example,  than 
six  and  one-quarter  inches,  we  may  conclude  that  there  is  a  consider- 
able narrowing  of  the  antero-posterior  diameter  of  the  brim,  the  extent 
of  which  we  must  endeavor  to  ascertain  by  other  means.  If,  on  the 
other  hand,  the  measurement  equals  or  exceeds  the  average  (seven  and 
one-half  to  eight  and  one-half  inches),  such  contraction  may  be  ex- 
cluded. If  we  find  all  these  external  measurements  to  be  normal  both 
as  to  length  and  relation,  then  we  may  safely  conclude  that  the  pelvis 
also  is  normal,  and  no  further  examination  is  required. 

For  the  purpose  of  making  these  measurements,  Baudelocque's 
compos  d'epaisseur  can  be  used  (Fig.  148),  or  Dr.  Lazarewitch's  elegant 

FIG.  148. 


Pelvimeter. 


universal  pelvimeter,  which  can  be  adopted  also  for  internal  pelvim- 
ctrv;  but,  in  the  absence  of  these  special  contrivances,  an  ordinary 
pair  of  callipers,  such  as  are  used  by  carpenters,  can  be  made  to  answer 
the  desired  object. 

These  external  measurements  must  be  corroborated,  when  abnormal, 
by  internal,  chiefly  of  the  antero-posterior  diameter,  by  which  alone 


410 


LABOR. 


we  can  estimate  the  amount  of  the  deformity.  We  endeavor  to  find, 
in  the  first  place,  the  length  of  the  inclined  conjugate,  between  the 
lower  edge  of  the  symphysis  pubis  and  the  promontory  of  the  sacrum, 
which  averages  about  half  an  inch  more  than  the  true  conjugate.  This 
is  best  done  by  placing  the  patient  on  her  back,  with  the  hips  well 
raised.  The  index  and  middle  fingers  of  the  right  hand  are  then  in- 
troduced into  the  vagina,  and  the  perineum  is  pressed  steadily  back- 
ward, so  as  to  overcome  the  resistance  it  offers.  The  tip  of  the  middle 
finger  is  passed  steadily  upward  until  it  reaches  the  promontory  of  the 
sacrum,  which  is  recognized  by  the  breadth  of  the  cartilage  between  it 
and  the  last  lumbar  vertebra.  Care  must  be  taken  not  to  mistake  the 
junction  between  the  first  and  second  lumbar  vertebra?,  occasionally 


FIG.  149. 


Greenhalgh's  pelvimeter. 

unduly  prominent,  for  the  true  promontory.  If  the  tip  of  the  finger 
can  reach  the  promontory  of  the  sacrum,  the  radial  side  of  the  hand  is 
raised  so  as  to  touch  the  lower  edge  of  the  ptibes.  A  mark  is  made 
Avith  the  nail  of  the  index  of  the  left  hand  on  that  part  of  the  index 
finger  of  the  right  hand  which  rests  under  the  symphysis,  and  then  the 
distance  from  this  to  the  tip  of  the  finger,  less  one-half  to  three-quarters 
of  an  inch,  may  be  taken  to  indicate  the  measurement  of  the  true  con- 
jugate of  the  brim.  Various  pelvimeters  have  been  devised  to  make 
the  same  measurements,  such  as  Lumley  Earle's,  Lazarewitch's,  which 
is  similar  in  principle,  and  Van  Huevel's ;  the  best  and  simplest,  I 
think,  is  that  invented  by  Dr.  Greenhalgh  (Fig.  149).  It  consists 
of  a  movable  rod,  attached  to  a  flexible  band  of  metal  which  passes 
around  the  palm  of  the  examining  hand.  At  the  distal  end  of  the  rod 
is  a  curved  portion,  which  passes  over  the  radial  edge  of  the  index 
finger.  The  examination  is  made  in  the  usual  way,  and  when  the 

•  *— '  v   J 


DEFORMITIES    OF    THE    PELVIS.  411 

point  of  the  finger  is  resting  on  the  promontory  of  the  sacrum,  the  rod 
is  withdrawn  until  it  is  arrested  by  the  posterior  surface  of  the  sym- 
physis,  the  exact  measurement  of  the  inclined  conjugate  being  then 
read  off  the  scale. 

It  is  to  be  remembered  that  this  procedure  is  useless  in  the  slighter 
degrees  of  contraction,  in  which  the  promontory  of  the  sacrum  cannot 
be  easily  reached.  Dr.  Ramsbotham  proposed  to  measure  the  conju- 
gate by  spreading  out  the  index  and  middle  fingers  internally,  the  tip 
of  one  resting  on  the  promontory,  the  other  behind  the  symphysis 
pubis ;  and  then  withdrawing  them,  in  the  same  position,  and  meas- 
uring the  distance  between  them.  This  manoeuvre  I  believe  to  be 
impracticable. 

Whenever,  in  actual  labor,  we  wish  to  ascertain  the  condition  of 
the  pelvis  accurately,  the  patient  should  be  anaesthetized,  and  the 
wrhole  hand  introduced  into  the  vagina  (which  could  not  otherwise  be 
done  without  causing  great  pain),  and  the  proportions  of  the  pelvis, 
and  the  relations  of  the  head  to  it,  thoroughly  explored ;  and,  if  what 
has  been  said  as  to  the  mechanism  of  delivery  in  these  cases  be  borne 
in  mind,  this  may  aid  us  in  determining  the  kind  of  deformity  exist- 
ing. In  this  way  contractions  about  the  outlet  of  the  pelvis  can  also 
be  pretty  generally  made  out. 

The  obliquely  contracted  pelvis  cannot  be  determined  by  any  of 
these  methods,  but  certain  external  measurements,  as  Naegele  has 
pointed  out,  will  readily  enable  us  to  recognize  its  existence.  It  will 
be  found  that  measurements  which  in  the  healthy  pelvis  ought  to  be 
equal  are  unequal  in  the  obliquely  distorted  pelvis.  The  points  of 
measurement  are  chiefly  :  1.  From  the  tuberosity  of  the  ischium  on 
one  side  to  the  posterior  superior  spine  of  the  ilium  on  the  other.  2. 
From  the  anterior  superior  iliac  spine  on  the  one  side  to  the  posterior 
superior  on  the  opposite.  3.  From  the  trochanter  major  of  one  side 
to  the  posterior  superior  iliac  spine  on  the  other.  4.  From  the  lower 
edge  of  the  symphysis  pubis  to  the  posterior  superior  iliac  spine  on 
either  side.  5.  From  the  spinous  process  of  the  last  lumbar  vertebra 
to  the  anterior  superior  spine  of  the  ilium  on  either  side. 

If  these  measurements  differ  from  each  other  by  half  an  inch  to  an 
inch,  the  existence  of  an  obliquely  deformed  pelvis  may  be  safely 
diagnosed.  The  diagnosis  can  be  corroborated  by  placing  the  patient 
in  the  erect  position,  and  letting  fall  two  plumb-lines,  one  from  the 
spines  of  the  sacrum,  the  other  from  the  symphysis  pubis.  In  a 
healthy  pelvis  these  will  fall  in  the  same  plane,  but  in  the  oblique 
pelvis  the  anterior  line  will  deviate  considerably  toward  the  unaffected 
side. 

Treatment. — The  proper  management  of  labor  in  contracted  pelvis 
is,  even  up  to  this  time,  one  of  the  most  vexed  questions  in  midwifery, 
notwithstanding  the  immense  amount  of  discussion  to  which  it  has 
given  rise  ;  and  the  varying  opinions  of  accoucheurs  of  equal  experi- 
ence afford  a  strong  proof  of  the  difficulties  surrounding  the  subject. 
This  remark  applies,  of  course,  only  to  the  lesser  degree  of  deformity, 
in  which  the  birth  of  a  living  child  is  not  hopeless.  When  the  antero- 
posterior  diameter  of  the  brim  measures  from  two  and  three-quarters. 


412  LABOR. 

to  three  inches,  it  is  universally  admitted  that  the  destruction  of  the 
child  is  inevitable,  unless  the  pelvis  be  so  small  as  to  necessitate  the 
performance  of  the  Caesarean  section.  But  when  it  is  between  three 
inches  and  the  normal  measurement,  the  comparative  merits  of  the 
forceps,  turning,  and  the  induction  of  premature  labor  form  a  fruitful 
theme  for  discussion.  With  one  class  of  accoucheurs  the  forceps  is 
chiefly  advocated,  and  turning  admitted  as  an  occasional  resource  when 
it  has  failed;  and  this,  indeed,  speaking  broadly,  may  be  said  to 
have  been  the  general  view  held  in  England.  More  recently  we  find 
German  authorities  of  eminence,  such  as  Schroeder  and  Spiegelberg, 
giving  turning  the  chief  place,  and  condemning  the  forceps  altogether 
in  contracted  pelves,  or  at  least  restricting  its  use  within  very  narrow 
limits.  More  strangely  still  we  find,  of  late,  that  the  induction  of 
premature  labor,  on  the  origination  and  extension  of  which  British 
accoucheurs  have  always  prided  themselves,  is  placed  without  the  pale, 
and  spoken  of  as  injurious  and  useless  in  reference  to  pelvic  deformi- 
ties. To  see  our  way  clearly  amongst  so  many  conflicting  opinions  is 
by  no  means  an  easy  task,  and  perhaps  we  may  best  aid  in  its  accom- 
plishment by  considering  separately  the  three  operations  in  so  far  as 
they  bear  on  this  subject,  and  pointing  out  briefly  what  can  be  said 
for  and  against  each  of  them. 

The  Forceps. — In  England  and  in  France  it  is  pretty  generally 
admitted  that  in  the  slighter  degrees  of  contraction  the  most  reliable 
means  of  aiding  the  patient  is  by  the  forceps.  It  should  be  remem- 
bered that  the  operation,  under  such  circumstances,  is  always  much 
more  serious  than  in  ordinary  labors  simply  delayed  from  uterine 
inertia,  when  there  is  ample  room,  and  the  head  is  in  the  cavity  of 
the  pelvis ;  for  the  blades  have  to  be  passed  up  very  high,  often  when 
the  head  is  more  or  less  movable  above  the  brim,  and  much  more 
traction  is  likely  to  be  required.  For  these  reasons  artificial  assist- 
ance, when  pelvic  deformity  is  suspected,  is  not  to  be  lightly  or  hur- 
riedly resorted  to.  Nor,  fortunately,  is  it  always  necessary,  for  if  the 
pains  be  sufficiently  strong,  and  the  contraction  not  too  great  to  pre- 
vent the  head  engaging  at  all,  after  a  lapse  of  time  it  will  become  so 
moulded  in  the  brim  as  to  pass  even  a  considerable  obstruction.  In 
all  cases,  therefore,  sufficient  time  must  be  given  for  this ;  and  if  no 
suspicious  symptoms  exist  on  the  part  of  the  mother — no  elevation  of 
temperature,  dryness  of  the  vagina,  rapid  pulse,  and  the  like,  and  the 
foetal  heart  sounds  continue  to  be  normal — labor  may  be  allowed  to 
go  on  for  some  hours  after  the  rupture  of  the  membranes,  so  as  to  give 
Nature  a  chance  of  completing  the  delivery.  When  this  seems  hope- 
less, the  intervention  of  art  is  called  for. 

The  forceps  is  generally  considered  to  be  applicable  in  all  degrees 
of  contraction,  from  the  standard  measurement  down  to  about  three 
and  a  quarter  inches  in  the  conjugate  of  the  brim.  There  can  be  no 
doubt  that  in  such  cases  traction  with  the  forceps  often  enables  us  to 
effect  delivery,  when  the  natural  efforts  have  proved  insufficient,  and 
holds  out  a  very  fair  hope  of  saving  the  child.  Out  of  seventeen 
cases  in  which  the  high  forceps  operation  was  resorted  to  for  pelvic 
deformity,  reported  by  Stanesco,  in  thirteen  living  children  were  born. 


DEFORMITIES    OF    THE    PELVIS.  413 

If  the  length  of  the  labor,  and  the  long-continued  compression  to 
which  the  child  has  been  subjected,  be  borne  in  mind,  this  result  must 
be  considered  very  favorable. 

What  are  the  objections  which  have  been  brought  against  the  opera- 
tion? These  have  been  principally  made  by  Schroeder  and  other 
German  writers.  They  are,  chiefly,  the  difficulty  of  passing  the  in- 
strument ;  the  risk  of  injuring  the  maternal  structures;  and  the  sup- 
position that,  as  the  blades  must  seize  the  head  by  the  forehead  and 
occiput,  their  compressive  action  will  diminish  its  longitudinal  and 
increase  its  transverse  diameter  (which  is  opposed  to  the  contracted 
part  of  the  brim),  and  so  enlarge  the  head  just  where  it  ought  to  be 
smallest.  There  is  little  doubt  that  these  writers  much  exaggerate 
the  compressive  power  of  the  forceps.  Certainly,  with  those  generally 
used  in  this  country,  any  disadvantage  likely  to  accrue  from  this  is 
more  than  counterbalanced  by  the  traction  on  the  head ;  and  the  fact 
that  minor  degrees  of  obstruction  can  be  thus  overcome,  with  safety 
both  to  the  mother  and  child,  is  abundantly  proved  by  the  numberless 
cases  in  which  the  forceps  has  been  used. 

It  is  very  likely  that  the  forceps  does  not  act  equally  well  in  all 
cases.  When  the  head  is  loose  above  the  brim  ;  when  the  contraction 
is  chiefly  limited  to  the  antero-posterior  diameter,  and  there  is  abun- 
dance of  room  at  the  sides  of  the  pelvis  for  the  occiput  to  occupy  after 
version ;  and  when,  as  is  usual  in  these  cases,  the  anterior  fontanelle 
is  depressed  and  the  head  lies  transversely  across  the  brim,  turning  is 
certainly  the  safer  operation  for  the  mother,  and  the  easier  performed. 
When,  on  the  other  hand,  the  head  has  engaged  in  the  brim,  and  has 
become  more  or  less  impacted,  it  is  obvious  that  version  could  not  be 
performed  without  pushing  it  back,  which  may  be  neither  easy  nor 
safe.  In  the  generally  contracted  pelvis,  in  which  the  head  enters  in 
an  exaggerated  state  of  flexion  and  lies  obliquely,  the  posterior 
fontanelle  being  much  depressed,  the  forceps  is  more  suitable. 

Mechanical  Advantage  of  Turning  in  Certain  Cases. — The 
special  reasons  why  version  sometimes  succeeds  when  the  forceps  fails, 
or  why  it  may  be  elected  from  the  first  as  a  matter  of  choice,  have 
been  by  no  one  better  pointed  out  than  by  Sir  James  Simpson. 
Although  the  operation  was  performed  by  many  of  the  older  obstetri- 
cians, its  revival  in  modern  times,  and  the  clear  enunciation  of  its 
principles,  can  undoubtedly  be  traced  to  his  writings.  He  points  out 
that  the  head  of  the  child  is  shaped  like  a  cone,  its  narrowest  portion 
the  base  of  the  cranium  (Fig.  150,  6  6),  measuring,  on  an  average,  from 
one-half  to  three-quarters  of  an  inch  less  than  the  broadest  portion 
(Fig.  150.  a  a),  viz.,  the  bi-parietal  diameter.  In  ordinary  head  pres- 
entations the  latter  part  of  the  head  has  to  pass  first ;  but  if  the  feet 
are  brought  down,  the  narrow  apex  of  the  cranial  cone  is  brought  first 
into  apposition  with  the  contracted  brim,  and  can  be  more  easily  drawn 
through  than  the  broader  base  can  be  pushed  through  by  the  uterine 
contractions.  Nor  is  this  the  only  advantage,  for,  after  turning,  the 
narrower  bi-temporal  diameter  (Fig.  151,  6  6) — which  measures,  on  an 
average,  half  an  inch  less  than  the  bi-parietal  (Fig.  151,  a  a) — is  brought 
into  contact  with  the  contracted  conjugate,  while  the  broader  bi-parietal 


414 


LABOR. 


lies  in  the  comparatively  wide  space  at  the  side  of  the  pelvis  (Fig.  152). 
These  mechanical  considerations  are  sufficiently  obvious,  and  fully 
explain  the  success  which  has  often  attended  the  performance  of  the 
operation. 


FIG.  150. 


FIG.  lol. 


Section  of  foetal  cranium,  showing 
its  conical  form. 


Showing  the  greater  breadth  of  the 
bi-parietal  diameter  of  the  foetal 
cranium.  (After  SIMPSON.) 


FIG.  152. 


Showing  the  greater  space  for  the  bi-parietal  diameter  at  the  side  of  the  pelvis  in  certain 
cases  of  deformity.    (After  SIMPSON.) 

It  is  generally  admitted  that  it  may  be  possible,  for  the  reasons  just 
mentioned,  to  deliver  a  living  child  by  turning  through  a  pelvis  con- 
tracted beyond  the  point  which  would  permit  of  a  living  child  being 
extracted  by  the  forceps.  Many  obstetricians  believe  that  it  is  possible 
to  deliver  a  living  child  by  turning  in  a  pelvis  contracted  even  to  the 
extent  of  two  and  three-quarters  inches  in  the  conjugate  diameter. 
Barnes  maintains  that,  although  an  unusually  compressible  head  may 
be  drawn  through  a  pelvis  contracted  to  three  inches,  the  chance  of 
the  child  being  born  alive  under  such  circumstances  must  necessarily 
be  small,  and  that  from  three  and  a  quarter  inches  to  the  normal  size 
must  be  taken  as  the  proper  limits  of  the  operation. 

That  delivery  is  often  possible  by  turning,  after  the  forceps  and  the 
natural  powers  have  failed,  and  when  no  other  resource  is  left  but 
the  destruction  of  the  child,  must,  I  think,  be  admitted  by  all ;  for  the 
records  of  obstetrics  are  full  of  such  cases.  To  take  one  example 
only,  Dr.  Braxton  Hicks1  records  four  cases  in  which  the  forceps  was 


1  Guy's  Hospital  Reports,  1869-70,  vol.  xv.  3d  ser.  p.  501. 


DEFORMITIES    OF    THE    PELVIS.  415- 

tried  unsuccessfully,  in  all  of  which  version  \vas  used,  three  of  the 
children  being  born  alive.  Here  are  the  lives  of  three  children  rescued 
from  destruction,  within  a  short  period,  in  the  practice  of  one  man ; 
and  a  fact  like  this  would  of  itself  be  ample  justification  of  the  attempt 
to  deliver  by  turning,  when  the  child  was  known  to  be  alive,  and 
other  means  had  failed.  The  possibility  that  craniotomy  may  still  be 
required  is  no  argument  against  the  operation ;  for  although  perfora- 
tion of  the  after-coming  head  is  certainly  not  so  easy  as  perforation  of 
a  presenting  head,  it  is  not  so  much  more  difficult  as  to  justify  the 
neglect  of  an  experiment  by  which  it  may  possibly  be  altogether 
avoided. 

The  original  choice  of  turning  is  a  more  difficult  question  to  decide. 
The  most  generally  received  opinion  in  the  present  day  among  scientific 
obstetricians  is  that  in  the  simply  flattened  pelvis,  with  an  antero- 
posterior  diameter  of  not  less  than  two  and  three-quarters  inches,  turn- 
ing is  the  preferable  operation.  [']  In  every  case  of  doubt  it  is  desirable 
thoroughly  to  anaesthetize  the  patient  and  make  a  careful  examination 
with  the  whole  hand  in  the  vagina.  If  we  find  the  sagittal  suture 
lying  transversely,  one  parietal  bone  on  a  lower  line  than  the  other, 
and  if  both  fontanelles  are  easily  within  reach,  and  some  space  exists 
at  the  sides  of  the  pelvis  beside  the  forehead  and  occiput,  then  turning 
is  the  procedure  most  likely  to  succeed,  and  the  descent  of  the  head 
after  version  can  be  very  materially  assisted  by  strong  pressure  applied 
from  above  by  an  assistant,  as  has  been  well  pointed  out  by  Goodell.2 
If,  on  the  other  hand,  the  anterior  fontanelle  is  high  up,  and  out  of 
reach,  the  head  being  distinctly  flexed,  we  have  to  do  with  a  generally 
contracted  pelvis,  and  the  forceps  is  the  preferable  operation. 

When  the  contraction  is  below  three  inches  in  the  conjugate,  or 
when  the  forceps  or  turning  has  failed,  no  resource  is  left  but  the 
destruction  of  the  foetus,  or  the  Csesareau  section  [or  symphyseotomy. 
—ED.]. 

The  Induction  of  Premature  Labor. — The  induction  of  premature 
labor  as  a  means  of  avoiding  the  risk  of  delivery  at  term,  and  of 
possibly  saving  the  life  of  the  child,  must  now  be  studied.  The  estab- 
lished rule  in  England  is,  that  in -all  cases  of  pelvic  deformity  the 
existence  of  which  has  been  ascertained  either  by  the  experience  of 
former  labors  or  by  accurate  examination  of  the  pelvis,  labor  should 
be  induced  previous  to  the  full  period,  so  that  the  smaller  and  more 
compressible  head  of  the  premature  foetus  may  pass  where  that  of  the 
foetus  at  term  could  not.  The  gain  is  a  double  one,  partly  the  lessened 
risk  to  the  mother,  and  partly  the  chance  of  saving  the  child's  life. 

The  practice  is  so  thoroughly  recognized  as  a  conservative  and 
judicious  one  that  it  might  be  deemed  unnecessary  to  argue  in  its 
favor,  were  it  not  that  some  eminent  authorities  have  of  late  years 
tried  to  show  that  it  is  better  and  safer  to  the  mother  to  leave  the 
labor  to  come  on  at  term  ;  and  that  the  risk  to  the  child  is  so  great  in 
artificially  induced  labor  as  to  lead  to  the  conclusion  that  the  opera- 

f1  At  two  and  three-quarters  c.v.,  symphyseotomy  avails  to  deliver  a  living  foetus,  and  is 
becoming  a  favorite  operation  in  our  country.— ED.] 
a  Amer.  Journ.  of  Obstet.,  1875-76,  vol.  viii.  p.  193. 


416  LABOR. 

tion  should  be  altogether  abandoned,  except,  perhaps,  in  the  extreme 
distortion  in  which  the  Csesarean  section  might  otherwise  be  necessary. 
Prominent  amongst  those  who  hold  these  views  are  Spiegelberg  and 
Litzmann,  and  they  have  been  supported,  in  a  modified  form,  by 
Matthews  Duncan.  Spiegelberg1  tries  to  show,  by  a  collection  of 
cases  from  various  sources,  that  the  results  of  induced  labor  in  con- 
tracted pelves  are  much  more  unfavorable  than  when  the  cases  are  left 
to  Nature;  that  in  the  latter  the  mortality  of  the  mothers  is  6.6  per 
cent,  and  of  the  children  28.7  per  cent.,  whereas  in  the  former  the 
maternal  deaths  are  15  per  cent,  and  the  infantile  66.9  per  cent. 
Litzmann2  arrives  at  not  very  dissimilar  results — namely,  6.9  per  cent, 
of  the  mothers  and  20.3  per  cent,  of  the  children  in  contracted  pelvis 
at  term,  and  14.7  per  cent,  of  the  mothers  and  55.8  per  cent,  of  the 
children,  in  artificially  induced  premature  labor. 

If  these  statistics  were  reliable,  inasmuch  as  they  show  a  very 
decided  risk  to  the  mother,  there  might  be  great  force  in  the  argument 
that  it  would  be  better  to  leave  the  cases  to  run  the  chance  of  delivery 
at  term.  It  is,  however,  very  questionable  whether  they  can  be  taken, 
in  themselves,  as  being  sufficient  to  settle  the  question.  The  fallacy 
of  determining  such  points  by  a  mass  of  heterogeneous  cases,  collected 
together  without  a  careful  sifting  of  their  histories,  has  over  and  over 
again  been  pointed  out ;  and  it  would  be  easy  enough  to  meet  them  by 
an  equal  catalogue  of  cases  in  which  the  maternal  mortality  is  almost 
nil.  The  results  of  the  practice  of  many  authorities  are  given  in 
Churchill's  work,  where  we  find,  for  example,  that  out  of  forty-six 
cases  of  Merriman's,  not  one  proved  fatal.  The  same  fortunate  result 
happened  in  sixty-two  cases  of  Ramsbotham's.  His  conclusion  is 
that  "  there  is  undoubtedly  some  risk  incurred  by  the  mother,  but  not 
more  than  by  accidental  premature  labor,"  and  this  conclusion,  as 
regards  the  mother,  is  that  which  has  long  ago  been  arrived  at  by  the 
majority  of  British  obstetricians,  who  undoubtedly  have  more  expe- 
rience of  the  operation  than  those  of  any  other  nation.  With  regard 
to  the  child,  even  if  the  German  statistics  be  taken  as  reliable,  they 
would  hardly  be  accepted  as  contra-indicating  the  operation,  inasmuch 
as  it  is  intended  to  save  the  mother  from  the  dangers  of  the  more 
serious  labor  at  term,  and,  in  many  cases,  to  give  at  least  a  chance  to 
the  child,  whose  life  would  otherwise  be  certainly  sacrificed.  The 
result,  moreover,  must  depend  to  a  great  extent  on  the  method  of  oper- 
ation adopted,  for  many  of  the  plans  of  inducing  labor  recommended 
are  certainly,  in  themselves,  not  devoid  of  danger  both  to  the  mother 
and  the  child.  It  may,  I  think,  be  admitted,  as  Duncan  contends, 
that  the  operation  has  been  more  often  performed  than  is  absolutely 
necessary,  and  that  the  higher  degrees  of  pelvic  contraction  are  much 
more  uncommon  than  has  been  supposed  to  be  the  case.  That  is  a 
very  valid  reason  for  insisting  on  a  careful  and  accurate  diagnosis,  but 
not  for  rejecting  an  operation  which  has  so  long  been  an  established 
and  favorite  resource. 

When  the  induction  of  labor  has  been  determined  on,  the  precise 

ryn''  187°'  B(1>  -  S' 1-    "  Ueber  den  Werth  der  kunstlichen  Fruhgeburt. 


DEFORMITIES    OF    THE    PELVIS. 


417 


lanes. 
6  or    7  ind 

8  "     9 
10   "  11 

1 
2  or    3 
4    "    5 
5    "    6 

uce  lat 

•or  at  30th  wee] 
31st 
32d 
33d 
33d 
34th 
35th 
36th 

period  at  which  it  should  be  resorted  to  becomes  a  question  for  anxious 
consideration,  since  the  longer  it  is  delayed  the  greater,  of  course,  are 
the  dangers  for  the  child.  Many  tables  have  been  constructed  to  guide 
us  on  this  point,  which  are  not,  on  the  whole,  of  so  much  service  as 
they  might  appear  to  be,  on  account  of  the  difficulty  of  determining 
with  minute  accuracy  the  amount  of  contraction.  The  following, 
however,  which  is  drawn  up  by  Kiwisch,  may  serve  for  a  guide  an 
settling  this  question : 

Inches. 

When  the  sacro-pubic  diameter  is  2  and 

2 

2 
3 
3 


In  cases  of  moderate  deformity,  when  labor  pains  have  been  induced, 
the  further  progress  of  the  case  may  be  left  to  Nature ;  but  in  more 
marked  cases,  as  in  those  below  three  inches,  it  will  often  be  found 
necessary  to  assist  delivery  by  turning  or  by  the  forceps,  the  former 
being  here  specially  useful,  on  account  of  the  extreme  pliability  of  the 
head,  and  the  facility  with  which  it  may  be  drawn  through  the  con- 
tracted brim.  By  thus  combining  the  two  operations  it  may  be  quite 
possible  to  secure  the  birth  of  a  living  child  even  in  pelves  very  con- 
siderably deformed. 

Production  of  Abortion  in  Extreme  Deformity. — When  the 
contraction  is  so  great  as  to  necessitate  the  induction  of  the  labor  before 
the  sixth  month,  or,  in  other  words,  before  the  child  has  reached  a 
viable  age,  it  would  be  preferable  to  resort  to  a  very  early  production 
of  abortion.  The  operation  is  then  indicated,  not  for  the  sake  of  the 
child,  but  to  save  the  mother  from  the  deadly  risk  to  which  she  would 
otherwise  be  subjected.  As  in  these  cases  the  mother  alone  is  con- 
cerned, the  operation  should  be  performed  as  soon  as  we  have  posi- 
tively determined  the  existence  of  pregnancy.  No  object  can  be  gained 
by  waiting  until  the  development  of  the  child  is  advanced  to  any 
extent,  and  the  less  the  foetus  is  developed,  the  less  will  be  the  pain 
and  the  risk  the  mother  has  to  undergo.  There  is  no  amount  of  de- 
formity, however  great,  in  which  we  could  not  succeed  in  bringing  on 
miscarriage  by  some  of  the  numerous  means  at  our  disposal ;  and,  in 
spite  of  Dr.  Radford's  objections,  who  maintains  that  the  obstetrician 
is  not  justified  in  sacrificing  the  life  of  a  human  being  more  than  once, 
when  the  mother  knows  that  she  cannot  give  birth  to  a  viable  child, 
there  are  few  practitioners  who  would  not  deem  it  their  duty  to  spare 
the  mother  the  terrible  dangers  of  the  Caesarean  section. 

[We  no  longer  on  this  side  of  the  Atlantic  regard  this  operation  as 
terribly  dangerous,  neither  is  it  thus  feared  in  Glasgow,  Leipzig,  Dresden, 
and  Vienna,  where  it  has  had  a  mortality  of  7  to  10  per  cent,  in  the 
last  decade.  In  our  own  country,  but  two  women  died  out  of  the  last 
twcntv,  covering  three  years,  and  but  three  children  were  lost,  one 
being  a  six  months  foetus.  One  woman  that  died,  did  so  after  twelve 
hours,  having  been  in  labor  seven  days  with  a  placenta  praevia  and  a 

rigid  cervix. — ED.! 

27 


418  LABOR. 


CHAPTER   XIII. 

HEMORRHAGE  BEFORE  DELIVERY:  PLACENTA  PR^VIA. 

THE  hemorrhages  which  are  the  result  of  an  abnormal  situation  of 
the  placenta,  partially  or  entirely  over  the  internal  os  uteri,  have 
formed  a  most  fruitful  theme  for  discussion.  The  explanation  of  the 
abnormal  placental  site,  the  sources  of  the  blood  and  the  causes  of  its 
escape,  the  means  adopted  by  Nature  for  its  arrest,  and  the  proper 
treatment,  have,  each  and  all  of  them,  been  the  subject  of  endless  con- 
troversies, which  are  not  yet  by  any  means  settled.  It  must  be  ad- 
mitted, too,  that  the  extreme  importance  of  the  subject  amply  justifies 
the  attention  which  has  been  paid  to  it ;  for  there  is  no  obstetric 
complication  more  apt  to  produce  sudden  and  alarming  effects,  and 
none  requiring  more  prompt  and  scientific  treatment. 

Definition. — By  placenta  prcevia  we  mean  the  insertion  of  the  pla- 
centa at  the  lower  segment  of  the  uterine  cavity,  so  that  a  portion  of 
it  is  situated,  wholly  or  partially,  over  the  internal  os  uteri.  In  the 
former  case  there  is  complete  or  central  placental  presentation,  in  the 
latter  an  incomplete  or  marginal  presentation. 

Causes. — The  causes  of  this  abnormal  placental  site  are  not  fully 
understood.  It  was  supposed  by  Tyler  Smith  to  depend  on  the  ovule 
not  having  been  impregnated  until  it  had  reached  the  lower  part  of  the 
uterine  cavity.  Cazeaux  suggests  that  the  uterine  mucous  membrane 
is  less  swollen  and  turgid  than  when  impregnation  occurs  at  the  more 
ordinary  place,  and  that,  therefore,  it  offers  less  obstruction  to  the 
descent  of  the  ovule  to  the  lower  part  of  the  uterine  cavity.  An 
abnormal  size,  or  unusual  shape,  of  the  uterine  cavity  may  also  favor 
the  descent  of  the  impregnated  ovule ;  the  former  probably  explains 
the  fact  that  placenta  prsevia  more  generally  occurs  in  women  who 
have  already  borne  children.  Miiller  believes  that  it  results  from 
uterine  contractions  occurring  shortly  after  conception,  which  force  the 
ovum  down  to  the  lower  part  of  the  uterine  cavity.  These  are  merely 
interesting  speculations  having  no  practical  value,  the  fact  being  un- 
doubted that,  in  a  not  inconsiderable  number  of  cases — estimated  1  >y 
Johnson  and  Sinclair  as  1  out  of  573 — the  placenta  is  grafted  partially 
or  entirely  over  the  uterine  orifice,  although  it  is  now  generally 
admitted  that  the  placenta  is  never  attached"  to  any  portion  of  the 
cervix  itself. 

History. — Placenta  prsevia  was  not  unknown  to  the  older  writers, 
who  believed  that  the  placenta  had  originally  been  situated  at  the 
fundus,  from  which  it  had  accidentally  fallen  to  the  lower  part  of  the 
uterus.  Portal,  Levret,  Roederer,  and  especially  the  British  author 
Eigby,  were  among  those  whose  observations  tended  to  improve  the 


HEMORRHAGE    BEFORE    DELIVERY.  419 

state  of  obstetrical  knowledge  as  to  its  real  nature.  To  Rigby  we  owe 
the  term  unavoidable  hemorrhage,  as  a  synonym  for  placenta  prtevia, 
and  as  distinguishing  hemorrhage  from  this  source  from  that  resulting 
from  separation  of  the  placenta  at  its  more  usual  position,  termed  by 
him,  in  centra-distinction,  accidental  hemorrhage.  These  names,  adopted 
by  most  writers  on  the  subject,  are  obviously  misleading,  as  they  assume 
an  essential  distinction  in  the  etiology  of  the  hemorrhage  in  the  two 
classes  of  cases,  which  is  not  always  warranted. 

It  is  of  the  utmost  importance  to  a  right  understanding  of  the  nature 
and  treatment  of  placenta  praevia  that  wre  should  fully  understand  the 
source  of  the  hemorrhage  and  the  manner  of  its  production  ;  but  \ve 
shall  be  able  to  discuss  this  subject  better  after  a  description  of  the 
symptoms. 

Symptoms. — Although  the  placenta  must  occupy  its  unusual  site 
from  the  earliest  period  of  its  formation,  it  rarely  gives  rise  to  appre- 
ciable symptoms  before  the  last  three  months  of  utero-gestation.  It  is 
far  from  unlikely,  however,  that  such  an  abnormal  situation  of  the 
placenta  may  produce  abortion  in  the  earlier  months,  the  site  of  its 
attachment  passing  unobserved. 

The  earliest  symptom  which  causes  suspicion  is  the  sudden  occur- 
rence of  hemorrhage,  without  any  appreciable  cause.  The  amount  of 
blood  lost  varies  considerably.  In  some  cases  the  first  hemorrhage  is 
comparatively  slight,  and  is  soon  spontaneously  arrested ;  but,  if  the 
case  be  left  to  itself,  the  flow  after  a  lapse  of  time — it  may  be  a  few 
days,  or  it  may  be  weeks — again  commences  in  the  same  unexpected 
way,  and  each  successive  hemorrhage  is  more  profuse.  The  losses 
show  themselves  at  diifereut  periods.  They  rarely  begin  before  the 
end  of  the  sixth  month,  more  often  nearer  the  full  period,  and  some- 
times not  until  labor  has  actually  commenced.  The  hemorrhage  is 
said,  but  this  is  doubtful,  to  often  coincide  with  what  would  have  been 
a  menstrual  period ;  possibly  on  account  of  the  physiological  conges- 
tion of  the  uterine  organs  then  present.  Should  the  first  loss  not  show 
itself  until  at  or  near  the  full  time,  it  may  be  tremendous,  and  a  few 
moments  may  suffice  to  place  the  patient's  life  in  jeopardy.  Indeed,  it 
may  be  safely  accepted  as  an  axiom,  that  once  hemorrhage  has  occurred, 
the  patient  is  never  safe ;  for  excessive  losses  may  occur  at  any  moment 
without  warning,  and  when  assistance  is  not  at  hand.  It  often  happens 
that  premature  labor  comes  on  after  one  or  more  hemorrhages. 

In  any  case  of  placenta  prsevia,  when  labor  has  commenced,  whether 
premature  or  at  the  full  time,  the  hemorrhage  may  become  excessive, 
and  witli  each  pain  fresh  portions  of  placenta  may-  be  detached  and 
fresh  vessels  torn  and  left  open.  Under  these  circumstances  the  blood 
nit  en  escapes  in  greater  quantity  with  each  successive  pain,  and 
diminishes  in  the  interval.  This  lias  long  been  looked  upon  as  a 
diagnostic  mark  by  which  we  can  distinguish  between  the  so-called 
"  unavoidable  "  and  "  accidental "  hemorrhage ;  in  the  latter  the  flow 
being  arrested  during  the  pains.  The  distinction,  however,  is  altogether 
fallacious.  The  tendency  of  uterine  contraction  in  placenta  praevia,  as 
in  all  other  forms  of  uterine  hemorrhage,  is  to  constrict  the  vessels 
from  which  the  blood  escapes,  and  so  to  lessen  the  flow.  The  appar- 


420  LABOR. 

eiitly  increased  flow  during  the  pains  depends  on  the  pains  forcing  out 
blood  which  has  already  escaped  from  the  vessels.  In  one  way,  up  to 
a  certain  point,  the  pains  do  favor  hemorrhage,  by  detaching  fresh  por- 
tions of  placenta ;  but  the  actual  loss  takes  place  chiefly  during  the 
intervals,  and  not  during*  the  continuance  of  contraction. 

On  vaginal  examination,  if  the  os  be  sufficiently  open  to  admit  the 
finger,  which  it  generally  is  on.  account  of  the  relaxation  produced  by 
the  loss  of  blood,  we  shall  almost  always  be  able  to  feel  some  portion 
of  presenting  placenta.  If  it  be  a  central  implantation,  -we  shall  find 
the  aperture  of  the  cervix  entirely  covered  by  a  thick,  boggy  mass 
which  is  to  be  distinguished  from  a  coagulum  by  its  consistence,  and 
by  its  not  breaking  down  under  the  pressure  of  the  finger.  Through 
the  placental  mass  we  may  feel  the  presenting  part  of  the  foetus ;  but 
not  as  distinctly  as  when  there  is  no  intervening  substance.  In  partial 
placental  presentations  the  bag  of  membranes,  and  above  it  the  head 
or  other  presentation,  will  be  found  to  occupy  a  part  of  the  circle  of 
the  os,  the  rest  being  covered  by  the  edge  of  the  placenta.  In  marginal 
presentations  we  may  only  be  able  to  make  out  the  thickened  edge  of 
the  afterbirth,  projecting  at  the  rim  of  the  os.  If  the  cervix  be  high, 
and  the  gestation  not  advanced  to  term,  these  points  may  not  be  easy 
to  make  out,  on  account  of  the  difficulty  of  reaching  the  cervix  ;  and, 
as  accurate  diagnosis  is  of  the  utmost  importance,  it  is  proper  to  intro- 
duce two  fingers,  or  even  the  whole  hand,  so  as  thoroughly  to  explore 
the  condition  of  the  parts.  The  lower  portion  of  the  uterine  ovoid 
may  be  observed  to  be  more  than  usually  thick  and  fleshy;  and 
Gendrin  has  pointed  out  that  ballottement  cannot  be  made  out.  The 
accuracy  of  our  diagnosis  may  be  confirmed,  in  doubtful  cases,  by 
finding  that  the  placental  bruit  is  heard  over  the  lower  part  of  the 
uterine  tumor. 

Dr.  Wallace1  has  suggested  that  vaginal  auscultation  may  be  service- 
able in  diagnosis,  and  states  that,  by  means  of  a  curved  wooden  stetho- 
scope, the  placental  bruit  may  be  heard  with  startling  distinctness. 
This  is,  hoM'ever,  a  manoeuvre  that  can  hardly  be  generallv  carried  out 
in  actual  practice. 

It  is  now  generally  admitted  by  authorities  that  the  immediate 
source  of  the  hemorrhage  is  the  lacerated  utero-placental  vessels.  Only 
a  few  years  ago  Sir  James  Y.  Simpson  advocated,  with  his  usual  energy, 
the  theory,  sustained  by  his  predecessor,  Dr.  Hamilton,  that  the  chief, 
if  not  the  only,  source  of  hemorrhage  was  the  detached  portion  of  the 
placenta  itself.  He  argued  that  the  blood  flowed  from  the  portion  of 
the  placenta  which  was  still  adherent  into  that  which  was  separated, 
and  escaped  from  the  surface  of  the  latter ;  and  on  this  supposition  he 
based  his  practice  of  entirely  separating  the  placenta,  having  observed 
that,  in  many  cases  in  which  the  afterbirth  had  been  expelled  before 
the  child,  the  hemorrhage  had  ceased.  The  fact  of  the  cessation  of  the 
hemorrhage,  when  this  occurs,  is  not  doubted ;  but  Simpson's  explana- 
tion is  contested  by  most  modern  writers,  prominent  among  whom  is 
Barnes,  who  has  devoted  much  study  to  the  elucidation  of  the  subject, 

1  Edin.  Med.  Journ  ,  vol.  1872-73,  p.  427 


HEMORRHAGE    BEFORE    DELIVERY.  421 

He  points  out  that  the  stoppage  of  the  hemorrhage  is  not  due  to  the 
separation  of  the  placenta,  but  to  the  preceding  or  accompanying  con- 
traction of  the  uterus,  which  seals  up  the  bleeding  vessels,  just  as  it 
does  in  other  forms  of  hemorrhage.  The  site  of  the  loss  was  actually 
demonstrated  by  the  late  Dr.  Mackenzie  in  a  series  of  experiments,  in 
which  he  partially  detached  the  placenta  in  pregnant  bitches,  and  found 
that  the  blood  flowed  from  the  walls  of  the  uterus,  and  not  from  the 
detached  surface  of  the  placenta.  The  arrangement  of  the  large 
venous  sinuses,  opening  as  they  do  on  the  uterine  mucous  membrane, 
favors  the  escape  of  blood  when  they  are  torn  across;  and  it  is  from 
them,  possibly  to  some  extent  also  from  the  uterine  arteries,  that  the 
blood  comes,  just  as  in  post-partum  hemorrhage,  when  the  whole, 
instead  of  a  part,  of  the  placental  site  is  bared. 

Various  explanations  have  been  given  of  the  causes  of  the  hemor- 
rhage. For  long  it  was  supposed  to  depend  on  the  gradual  expansion 
of  the  cervix  during  the  latter  months  of  pregnancy,  which  separated 
the  abnormally  placed  placenta.  It  has  been  seen,  however,  that  this 
shortening  of  the  cervix  is  apparent  only,  and  that  the  cervical  canal 
is  not  taken  up  into  the  uterine  cavity  during  gestation,  or,  at  all 
events,  only  during  the  last  week  or  so.  This,  therefore,  cannot  be 
admitted  as  an  explanation  of  placenta!  separation.  Jacquemier  pro- 
posed another  theory,  which  has  been  adopted  by  Cazeaux.  He 
maintains  that  during  the  first  six  months  of  utero-gestation  the 
superior  portion  of  the  uterus  is  more  especially  developed,  as  shown 
by  the  pyriform  shape  of  the  fundus  during  the  time  ;  and  that,  as  the 
placenta  is  usually  attached  in  that  situation,  and  then  attains  its 
maximum  of  development,  its  relations  to  its  attachments  are  undis- 
turbed. During  the  last  three  months  of  pregnancy,  on  the  contrary, 
the  lower  segment  of  the  uterus  develops  more  than  the  upper,  while 
the  placenta  remains  nearly  stationary  in  size ;  the  inevitable  result 
being  a  loss  of  proportion  between  the  cervix  and  the  placenta,  and 
the  detachment  of  the  latter.  There  are  various  objections  which  can 
be  brought  against  this  theory ;  the  most  important  being  that  there  is 
no  evidence  at  all  to  show  that  the  lower  segment  of  the  uterus  does 
expand  more  in  proportion  than  the  upper  during  the  latter  months  of 
pregnancy.  Barnes's  theory  is  based  on  the  supposition  that  the  loss 
of  relation  between  the  uterus  and  placenta  is  caused  by  excess  of 
growth  on  the  part  of  the  placenta  itself  over  that  of  the  cervix,  which 
is  not  adapted  for  its  attachment.  The  placenta,  on  this  hypothesis, 
grows  away  from  the  site  of  its  attachment,  and  hemorrhage  results. 
It  will  be  observed  that  neither  this  theory  nor  that  propounded  by 
Jacquemier  is  readily  reconcilable  with  the  fact  that  hemorrhage  fre- 
quently does  not  begin  until  labor  has  commenced  at  term.  Inasmuch 
as  the  loss  of  relation  between  the  placenta  and  its  attachments,  which 
they  both  presuppose,  must  exist  in  every  case  of  placenta  prrevia, 
hemorrhage  should  always  occur  during  some  part  of  the  last  three 
months  of  pregnancy.  Matthews  Duncan 1  has  recently  investigated 
the  whole  subject  at  length,  and  maintains  that  the  hemorrhages  are 

1  Edin.  Med.  Journ.,  vol.  1873-74,  pp.  885,  520 ;  and  Brit.  Med.  Journ.,  1873,  vol.  ii.  pp.  499,  597,  625. 


422  LABOK. 

accidental,  not  unavoidable,  being  due  to  causes  precisely  similar  to 
those  which  give  rise  to  the  occasional  hemorrhages  when  the  placenta 
is  normally  placed.  The  abnormal  situation  of  the  placenta  of  course 
renders  these  causes  more  apt  to  operate  ;  but  in  their  action  he  believes 
them  to  be  precisely  similar  to  those  of  accidental  hemorrhage,  properly 
so  called.  Separation  of  the  placenta  from  expansion  of  the  cervix  he 
believes  to  be  the  cause  of  hemorrhage  after  labor  has  begun,  and  then 
it  may  strictly  be  called  unavoidable ;  but  hemorrhage  is  comparatively 
seldom  so  produced  during  the -continuance  of  pregnancy.  "There 
are,"  says  Duncan,  "  four  ways  in  which  this  kind  of  hemorrhage  may 
occur : 

"1.  By  the  rupture  of  a  utero-placental  vessel  at  or  about  the  in- 
ternal os  uteri. 

"  2.  By  the  rupture  of  a  marginal  utero-placental  sinus  within  the 
area  of  spontaneous  premature  detachment,  when  the  placenta  is  in- 
serted not  centrally  or  covering  the  internal  os,  but  with  a  margin  at 
or  near  the  internal  os. 

"  3.  By  partial  separation  of  the  placenta  from  accidental  causes, 
such  as  a  jerk  or  fall. 

"4.  By  a  partial  separation  of  the  placenta,  the  consequence  of 
uterine  pains  producing  a  small  amount  of  dilatation  of  the  internal 
os.  Such  cases  may  be  otherwise  described  as  instances  of  miscarriage 
commencing,  but  arrested  at  a  very  early  stage." 

I  gee  no  reason  to  doubt  the  possibility  of  hemorrhage  being  due, 
in  many  cases,  to  the  first  three  causes,  and  in  its  production  it  would 
strictly  resemble  accidental  hemorrhage.  The  fourth  heading  refers 
the  hemorrhage  to  partial  separation,  in  consequence  of  commencing 
dilatation  of  the  cervix,  but  it  explains  the  dilatation  by  the  suppo- 
sition of  commencing  miscarriage.  This  latter  hypothesis  seems  to  be 
as  needless  as  those  which  presuppose  a  want  of  relation  between  the 
placenta  and  its  attachments.  We  know  that,  quite  independently  of 
commencing  miscarriage,  uterine  contractions  are  constantly  occurring 
during  the  continuance  of  pregnancy.  There  is  no  reason  to  suppose 
that  these  contractions  do  not  affect  the  cervical  as  well  as  the  fundal 
portions  of  the  uterus  ;  and  in  cases  in  which  the  placenta  is  situated 
partially  or  entirely  over  the  os,  one  or  more  stronger  contractions 
than  usual  may,  at  any  moment,  produce  laceration  of  the  placental 
attachments  in  that  neighborhood. 

Pathological  Changes  in  the  Placenta. — A  careful  examination 
of  the  placenta  may  show  pathological  changes  at  the  site  of  separation, 
such  as  have  been  described  by  Gendrin,  Simpson,  and  other  writers. 
They  probably  consist  of  thromboses  in  the  placental  cotyledons,  and 
effused  blood-clots,  variously  altered  and  decolorized,  according  to  the 
lapse  of  time  since  separation  took  place.  Changes  occur  in  the  por- 
tion of  the  placenta  overlying  the  os  uteri,  whether  separation  has 
occurred  or  not.  There  may  be  atrophy  of  the  placental  structure 
in  this  situation,  as  well  as  changes  of  form,  such  as  complete  or 
partial  separation  into  two  lobes,  the  junction  of  which  overlies  the 
os  uteri.1 

i  Sinelius :  Arch.  gen.  de  Med.,  1861,  torn.  ii. 


HEMORRHAGE    BEFORE    DELIVERY.  423 

The  history  of  delivery,  if  left  to  Nature,  is  specially  worthy  of 
study,  as  guiding  to  proper  rules  of  treatment.  It  sometimes  happens, 
when  the  pains  are  very  strong  and  the  delivery  rapid,  that  labor  is 
completed  without  any  hemorrhage  of  consequence.  "Although," 
says  Cazeaux,  "hemorrhage  is  usually  considered  to  be  inevitable 
under  such  circumstances,  yet  it  may  not  appear  even  during  the 
labor ;  and  the  dilatation  of  the  os  uteri  may  be  effected  without  the 
loss  of  a  drop  of  blood."  Again,  Simpson  conclusively  showed  that, 
when  the  placenta  was  expelled  before  the  birth  of  the  child,  all 
hemorrhage  ceased. 

Barnes's  theory  of  placenta  praevia,  which  has  been  pretty  generally 
adopted,  explains  satisfactorily  both  these  classes  of  cases. 

He  describes  the  uterine  cavity  as  divisible  into  three  zones  or 
regions.  When  the  placenta  is  situated  in  the  upper  or  middle  of 
these  zones,  no  separation  or  hemorrhage  need  occur  during  labor. 
When,  however,  it  is  situated  partially  or  entirely  in  the  lower  or 
cervical  zone,  the  expansion  of  the  cervix  during  labor  must  produce 
more  or  less  separation  and  consequent  loss  of  blood.  As  soon  as  the 
previous  portion  of  the  placenta  is  sufficiently  separated,  provided 
contraction  of  the  uterine  tissue  be  present  to  seal  up  the  mouths  of 
the  vessels,  hemorrhage  no  longer  takes  place.  The  placenta  may  not 
be  entirely  detached,  but  no  further  hemorrhage  occurs,  in  consequence 
of  the  remaining  portion  being  engrafted  on  the  uterus  beyond  the 
region  of  unsafe  attachment. 

In  the  former,  then,  of  these  classes  of  cases,  the  absence  of  hemor- 
rhage is  explained  on  this  theory,  by  the  pains  being  sufficiently  rapid 
and  strong  to  complete  the  separation  of  the  placental  attachment 
from  the  lower  cervical  zone  before  flooding  had  taken  place ;  in  the 
latter  it  ceases,  not  necessarily  because  the  entire  placenta  is  expelled, 
but  because  of  its  detachment  from  the  area  of  dangerous  im- 
plantation. 

The  amount  of  cervical  expansion  required  for  this  purpose  varies 
in  different  cases.  Dr.  Duncan1  estimates  the  limit  of  the  spontaneous 
detaching  area  to  be  a  circle  of  four  and  a  half  inches  diameter,  and 
that,  after  the  cervix  has  expanded  to  that  extent,  no  further  separa- 
tion or  hemorrhage  takes  place.  To  admit  of  the  passage  of  a  full- 
sized  head,  Barnes  estimates  that  expansion  to  about  a  circle  of  six 
inches  diameter  is  necessary ;  on  the  other  hand,  he  has  sometimes 
observed  "  that  the  hemorrhage  has  completely  stopped  when  the  os 
uteri  opened  to  the  size  of  the  rim  of  a  wineglass,  or  even  less." 

It  will-  be  seen  then  that  in  this,  as  in  every  other  form  of  puerperal 
hemorrhage,  the  tendency  of  uterine  contraction  is  to  check  the  hem- 
orrhage; and  that,  provided  the  pains  are  sufficiently  energetic,  Nature 
may  be  capable  of  stopping  the  flooding  without  artificial  aid.  It  is 
but  rarely,  however,  that  she  can  be  trusted  for  this  purpose ;  and  we 
shall  presently  see  that  these  theoretical  views  have  an  important 
practical  bearing  on  the  subject  of  treatment. 

Prognosis. — The  prognosis  to  both  the  mother  and  child  is  certainly 

i  Obst.  Trans.,  1874,  vol.  xv.  p.  189. 


424  LABOR. 

grave  in  all  eases  of  placenta  prsevia.  Read,  in  his  treatise  on  placenta 
praevia,  estimates  the  maternal  mortality,  from  the  statistics  of  u  large 
number  of  cases,  as  one  in  four  and  a  half  cases,  and  Churchill  as  one 
in  three.  This  is  unquestionably  too  high  an  estimate,  and  based  on 
statistics  the  accuracy  of  which  cannot  be  relied  on.  The  mortality 
will,  of  course,  greatly  depend  on  the  treatment  adopted.  Doubtless, 
if  cases  were  left  to  Nature,  the  result  would  be  quite  as  unfavorable 
as  Read  supposes.  But  if  properly  managed,  much  more  successful 
results  may  safely  be  anticipated.  Out  of  sixty-seven  cases  recorded 
by  Barnes,  the  deaths  were  six,  or  one  in  eight  and  a  half.  Under 
any  circumstances  the  risks  to  the  mother  are  very  great.  Churchill 
estimates  that  more  than  half  the  children  are  lost.  The  reasons  for 
the  great  danger  to  the  child  are  very  obvious,  subjected  as  it  is  to  the 
risk  of  asphyxia  from  the  loss  of  the  maternal  blood,  and  from  its 
oxygenation  being  carried  on  during  labor  by  a  placenta  which  is  only 
partially  attached;  many  children  also  perish  from  prematurity,  or 
from  malpresentation. 

Treatment. — Whenever,  in  the  latter  months  of  pregnancy,  a  sudden 
hemorrhage  occurs,  the  possibility  of  placenta  prsevia  will  naturally 
suggest  itself;  and  by  a  careful  vaginal  examination,  which  under 
such  circumstances  should  always  be  insisted  on,  the  existence  of  this 
complication  will  generally  be  readily  ascertained.  It  is  seldom  that 
the  os  is  not  sufficiently  dilated  to  enable  us  to  satisfy  ourselves  whether 
the  placenta  is  presenting. 

The  first  question  that  will  arise  is,  Are  we  justified  in  temporizing, 
using  means  to  check  the  hemorrhage,  and  allowing  the  pregnancy  to 
continue  ?  This  is  the  course  which  has  generally  been  recommended 
in  wrorks  on  midwifery.  We  are  told  to  place  the  patient  on  a  hard 
mattress,  not  to  heat  or  Overburden  her  with  clothes,  to  keep  her  abso- 
lutely at  rest,  to  have  the  room  cool  and  well  aired,  to  apply  cold 
cloths  to  the  vulva  and  lower  part  of  the  abdomen,  to  administer  cold 
and  acidulated  drinks  in  abundance,  and  to  prescribe  acetate  of  lead 
and  opium,  or  gallic  acid,  on  account  of  their  supposed  haemostatic 
effect.  Of  late  years  the  judiciousness  of  these  recommendations  has 
been  strongly  contested.  Xot  long  ago  an  interesting  discussion  took 
place  at  the  Obstetrical  Society  of  London,1  on  a  paper  in  which  Dr. 
Greenhalgh  advised  the  immediate  induction  of  labor  in  all  cases  of 
placenta  prsevia.  No  less  than  six  metropolitan  teachers  of  midwifery 
took  part  in  it,  and,  although  they  differed  in  details,  they  all  agreed 
as  to  the  unadvisability  of  allowing  pregnancy  to  progress  when  the 
existence  of  placenta  prsevia  had  been  distinctly  ascertained.  The 
reasons  for  this  course  are  obvious  and  unanswerable.  The  labor, 
indeed,  very  often  comes  on  of  its  own  accord  ;  but  should  it  not  do 
so  the  patient's  life  must  be  considered  to  be  always  in  jeopardy  until 
the  case  is  terminated,  for  no  one  can  be  sure  that  most  dangerous,  or 
even  fatal,  flooding  may  not  at  any  moment  come  on  ;  and  the  nearer 
to  term  the  patient  is,  the  greater  the  risk  to  which  she  is  subjected. 
Nor  is  the  safety  of  the  child  likely  to  be  increased  bv  delay.  Pro- 

i  Obst.  Trans.,  1865,  vol.  vi.  p.  188. 


HEMORRHAGE     BEFORE    DELIVERY.  425 

vided  it  has  arrived  at  a  viable  age,  the  chances  of  its  being  born  alive 
may  be  said  to  be  greater  if  pregnancy  be  terminated  at  once,  than  if 
repeated  floodings  occur.  I  think,  therefore,  that  it  may  be  safely 
laid  down  as  an  axiom,  that  no  attempt  should  be  made  to  prevent  the 
termination  of  pregnancy,  but  that  our  treatment  should  rather  con- 
template its  conclusion  as  soon  as  possible.  An  exception  may,  how- 
ever, be  made  to  this  rule  when  the  hemorrhage  occurs  for  the  first 
time  before  the  seventh  month  of  utero-gestation.  The  chances  of 
the  child  surviving  would  then  be  very  small,  and  if  the  hemorrhage 
be  not  alarming,  as  at  that  early  period  is  likely  to  be  the  case,  the 
measures  indicated  above  may  be  employed,  in  the  hope  of  carrying 
on  the  pregnancy  until  there  is  a  prospect  of  the  patient  being  de- 
livered of  a  living  child.  But  little  benefit  is  likely  to  accrue  from 
astringent  drugs.  Perfect  rest  in  bed  is  more  likely  to  be  beneficial 
than  anything  else. 

'When  the  period  of  pregnancy,  or  the  urgency  of  the  case,  deter- 
mines us  to  forego  any  attempt  at  temporizing,  there  are  various  plans 
of  treatment  to  be  considered.  These  are  chiefly:  1.  Puncture  of  the 
membranes.  2.  Plugging  the  vagina.  3.  Turning.  4.  Partial  or 
complete  separation  of  the  placenta.  It  will  be  well  to  consider  in 
detail  the  relative  advantages  of,  and  indications  for,  each  of  these. 
It  is  seldom,  however,  that  we  can  trust  to  any  one  per  se;  in  most 
cases,  two  or  more  are  required  to  be  used  in  combination. 

1.  Puncture  of  the  membranes  is  recommended  by  Barnes  as  the 
first  measure  to  be  adopted  in  all  cases  of  placenta  prsevia  sufficient 
to  cause  anxiety.  "It  is,"  he  says,  "the  most  generally  efficacious 
remedy,  and  it  can  always  be  applied."  The  primary  object  gained  is 
the  increase  of  uterine  contraction  by  the  evacuation  of  the  liquor 
amnii.  Although  the  first  effect  of  this  may  be  to  increase  the  flow 
of  blood  by  further  separation  of  the  placenta,  the  flooding  can  gen- 
erally be  commanded  by  plugging  until  the  os  is  sufficiently  dilated 
to  permit  the  passage  of  the  child.  As  a  rule,  there  is  no  great  diffi- 
culty in  effecting  the  puncture,  especially  if  the  placental  presentation 
be  only  partial.  A  quill,  or  other  suitable  contrivance,  guided  by  the 
examining  finger,  is  passed  through  the  cervix  and  pushed  through 
the  membranes.  In  complete  placenta  prsevia  it  may  not  be  so  easy 
to  effect  the  evacuation  of  the  liquor  amnii ;  and,  although  many 
authorities  advise  the  penetration  of  the  substance  of  the  placenta 
itself,  I  am  inclined  to  think  that  it  would  be  better  to  abandon  the 
attempt,  in  such  cases,  and  trust  to  other  methods  of  treatment. 

The  objections  which  have  been  raised  to  puncture  of  the  mem- 
branes are  chiefly  that  it  interferes  with  the  gradual  dilatation  of  the 
os,  and  renders  the  operation  of  turning  much  more  difficult.  The  os 
is  not,  however,  so  regularly  dilated  by  the  bag  of  membranes  in  cases 
of  placenta  prsevia  as  it  is  in  ordinary  labors.  Moreover,  as  the  cer- 
vical tissues  are  generally  relaxed  by  the  hemorrhage,  the  dilatation  is 
easily  effected.  Should  we  desire  to  dilate  the  os  preparatory  to  turn- 
ing, we  can  readily  do  so  by  means  of  fluid  dilators.  The  new  dilator 
of  Champetier  de  Kibes  will  probably  be  found  very  useful,  since  it 
will  not  only  rapidly  and  effectively  dilate  the  cervix  and  thus  pre- 


426  LABOR, 

pare  the  way  for  subsequent  turning,  but  also  act  as  an  efficient  plug. 
The  objections,  therefore,  are  not  so  weighty  as  they  might  have  been 
before  these  artificial  dilators  were  used.  I  am  inclined,  for  these 
reasons,  to  agree  with  the  recommendation  that  puncture  of  the  mem- 
branes should  be  resorted  to  in  all  cases  of  placenta  prrevia. 

2.  Plugging1  of  the  vagina,  or,  still  better,  of  the  cavity  of  the 
cervix  itself,  is  especially  serviceable  in  cases  in  which  the  os  is  not 
sufficiently  dilated  to  admit  of  turning,  or  of  separation  of  the  placenta, 
and  in  which  the  hemorrhage  still  continues  after  the  evacuation  of 
the  liquor  amnii.     By  means  of  this  contrivance  the  escape  of  blood 
is  effectually  controlled. 

A  good  way  of  plugging  is  to  introduce  a  sponge  tent  of  sufficient 
size  into  the  cervical  canal,  and  to  keep  it  in  situ  by  a  vaginal  plug ; 
the  best  material  for  the  latter,  and  the  method  of  introduction,  are 
described  under  the  head  of  Abortion  (p.  262).  The  sponge  tent  not 
only  controls  the  hemorrhage  more  effectually  than  any  other  means, 
but  is,  at  the  same  time,  effecting  dilatation  of  the  cervix.  It  cannot 
be  left  in  many  hours,  on  account  of  the  irritation  produced  and  of  the 
fetor  from  accumulating  vaginal  discharges,  and  the  consequent  risk 
of  septic  absorption.  This  is  by  no  means  slight,  and  it  is  now  prctty 
generally  recognized  that  the  plug  should  not  be  used  unless  other 
means  of  treatment  are  inapplicable  on  account  of  the  want  of  dilata- 
tion of  the  os.  As  long  as  it  is  in  position,  we  should  carefully 
examine,  from  time  to  time,  to  see  that  no  blood  is  oozing  past  it.  If 
preferred,  a  Barnes  bag  may  be  used  for  the  same  purpose. 

While  the  plug  is  in  situ  other  modes  of  exciting  uterine  action  may 
be  very  advantageously  employed,  such  as  a  firm  abdominal  bandage, 
occasional  friction  over  the  uterus,  and  repeated  doses  of  ergot.  The 
last  is  specially  recommended  by  Dr.  Greenhalgh,  who  used,  at  the 
same  time,  a  plug  formed  of  an  oblong  India-rubber  ball  inflated  with 
air  and  covered  with  spongio-piline. 

On  the  removal  of  the  plug  we  may  find  that  considerable  dilatation 
has  taken  place,  perhaps  to  a  sufficient  extent  to  admit  of  labor  being 
safely  concluded  by  the  natural  efforts.  In  that  case  we  shall  find 
that,  although  the  pains  continue,  no  fresh  hemorrhage  occurs.  Should 
it  do  so,  it  will  be  necessary  to  adopt  further  measures. 

3.  Turning  has  long  been  considered  the  remedy  par  excellence  in 
placenta  prsevia ;  and  it  is  of  unquestionable  value  in  suitable  cases. 
Much  harm,  however,  has  been  done  when  it  has  been  practised  before 
the  os  was  sufficiently  dilated  to  admit  of  the  passage  of  the  hand,  or 
when  the  patient  was  so  exhausted  by  previous  hemorrhage  as  to  be 
unable  to  bear  the  shock  of  the  operation.     The  records  of  many  fatal 
cases  in  the  practice  of  those  who  taught,  as  did  the  large  majority  of 
the  older  writers,  that  turning  at  all  risks  was  essential,  conclusively 
prove  this  assertion. 

It  is  most  likely  to  prove  serviceable  when,  either  at  first  or  after 
the  use  of  the  tampon,  the  os  is  sufficiently  dilated  to  admit  the  hand, 
and  when  the  strength  of  the  patient  is  not  much  enfeebled.  If  she 
have  a  small,  feeble,  and  thready  pulse,  it  is  certainly  inapplicable, 
unless  all  other  methods  of  arresting  the  hemorrhage  have  failed* 


HEMOKRHAQE    BEFORE    DELIVERY.  427 

And,  even  then,  it  would  be  well  to  attempt  to  rally  the  patient  from 
her  exhausted  state  by  stimulants,  etc.,  before  the  operation  is  com- 
menced. 

Provided  the  placental  presentation  be  partial,  the  operation  can  be 
performed  without  difficulty  in  the  usual  way.  In  central  implanta- 
tion the  passage  of  the  hand  may  give  rise  to  some  difficulty.  Dr. 
Rigby  recommends  that  it  should  be  pushed  through  the  substance  of 
the  placenta  until  it  reaches  the  uterine  cavity.  It  is  hardly  possible 
to  conceive  how  this  could  be  done  without  completely  detaching  the 
placenta,  and  still  less  to  understand  how  the  foatus  could  be  dragged 
through  the  aperture  thus  made.  It  will  be  far  better  to  pass  the 
hand  by  the  border  of  the  placenta,  separating  it  as  we  do  so ;  and,  if 
we  can  ascertain  to  which  side  of  the  cervix  it  is  least  attached,  that 
should  be  chosen  for  the  purpose.  In  all  cases  in  which  it  is  possible, 
turning  by  the  bi-polar  method  should  be  preferred.  In  cases  of 
placenta  prsevia  especially  it  offers  many  advantages.  The  operation 
can  be  soon  performed  ;  complete  dilatation  of  the  os  is  not  so  neces- 
sary ;  and  it  involves  less  bruising  of  the  cervix,  which  is  likely  to  be 
specially  dangerous.  When  once  a  lower  extremity  has  been  brought 
within  the  os,  the  delivery  should  not  be  hurried.  The  limb  of  the 
child  forms  a  plug,  which  effectually  prevents  all  further  loss;  and 
we  may  then  safely  wait  until  we  can  excite  uterine  contraction  and 
terminate  the  labor  with  safety.  The  results  of  this  method  of  treating 
placenta  prsevia  have  been  excellent.  Hoffmeier  relates  thirty-seven 
cases  managed  in  this  way  with  only  one  death,  and  Behm  thirty-five 
with  none.1  Fortunately,  the  relaxation  of  the  uterus,  which  is  so 
often  present,  facilitates  this  manner  of  performing  version,  and  it  can 
generally  be  successfully  accomplished.  Should  the  case  be  one  which 
is  otherwise  suitable  for  turning,  and  the  requisite  amount  of  dilata- 
tion of  the  cervix  not  be  present,  the  latter  can  generally  be  effected 
in  the  space  of  an  hour  or  more  (while  at  the  same  time  a  further  loss 
of  blood  is  effectually  prevented)  by  the  use  of  (fluid  dilators. 

4.  Entire  separation  of  the  placenta  was  originally  recommended 
by  Simpson  in  his  well-known  paper  on  the  subject.  The  reasons 
which  induced  him  to  recommend  it  have  already  been  stated.  It  is  a 
mistake  to  suppose,  however,  as  is  so  often  done,  that  he  intended  to 
recommend  it  in-  all  cases  alike.  This  supposition  he  was  always 
careful  to  deny.  He  advised  it  especially — 

1.  When  the  child  is  dead. 

2.  When  the  child  is  not  yet  viable. 

3.  When  the  hemorrhage  is  great  and  the  os  uteri  is  not  yet  suffi- 
ciently dilated  for  safe  turning.     This  was  the  state  in  eleven  out  of 
thirty -nine  cases  (Lee). 

4.  When  the  pelvic  passages  are  too  small  for  safe  and  easy  turning, 

5.  When  the  mother  is  too  exhausted  to  bear  turning. 

6.  When  the  evacuation  of  the  liquor  amnii  fails. 

7.  When  the  uterus  is  too  firmly  contracted  for  turning.2 

1  Zeitschr.  f.  Geburt.  tmd  Gynak.,  1882,  Bd.  viii.  S.  89;  1883,  Bd.  ix.   S.  373,   "Die  combinirte 
Wendung  bei  Placenta  Prcevia"." 

2  Selected  Obst.  Works,  p.  68. 


428  LABOR. 

These  are  very  much  the  cases  in  which  all  modern  accoucheurs 
would  exclude  the  operation  of  turning ;  and  it  was  specially  when 
that  Avas  unsuitable  that  Simpson  advised  extraction  of  the  placenta. 
As  his  theory  of  the  source  of  hemorrhage  is  now  almost  universally 
disbelieved,  so  has  the  practice  based  on  it  fallen  into  disuse,  and  it 
need  not  be  discussed  at  length.  It  is  very  doubtful  whether  the 
complete  separation  and  extraction  of  the  placenta  was  a  feasible  oper- 
ation;  unquestionably  it  can  be  by  no  means  so  easy  as  Simpson's 
writings  would  lead  us  to  suppose.  The  introduction  of  the  hand  far 
enough  to  remove  the  placenta  in  an  exhausted  patient  would  probably 
cause  as  much  shock  as  the  operation  of  turning  itself;  and  another 
very  formidable  objection  to  the  procedure  is  the  almost  certain  death 
of  the  child,  if  any  time  elapse  between  the  separation  of  the  placenta 
and  the  completion  of  delivery.  The  modification  of  this  method,  so 
strongly  advocated  by  Barnes,  is  certainly  much  easier  of  application, 
and  would  appear  to  answer  every  purpose  that  Simpson's  operation 
effected.  It  is  impossible  to  describe  it  better  than  in  Barnes's  own 
words  r1 

"The  operation  is  this:  Pass  one  or  two  fingers  as  far  as  they  will 
go  through  the  os  uteri,  the  hand  being  passed  into  the  vagina  if 
necessary ;  feeling  the  placenta,  insinuate  the  finger  between  it  and  the 
uterine  wall ;  sweep  the  finger  round  in  a  circle  so  as  to  separate  the 
placenta  as  far  as  the  finger  can  reach ;  if  you  feel  the  edge  of  the 
placenta,  where  the  membranes  begin,  tear  open  the  membranes  care- 
fully, especially  if  these  have  not  been  previously  ruptured  ;  ascertain, 
if  you  can,  Avhat  is  the  presentation  of  the  child  before  withdrawing 
your  hand.  Commonly,  some  amount  of  retraction  of  the  cervix  takes 
place  after  the  operation,  and  often  the  hemorrhage  ceases." 

It  will  be  seen  from  what  has  been  said,  that  no  one  rule  of  practice 
<?an  be  definitely  laid  down  for  all  cases  of  placenta  prsevia.  Our 
treatment  in  each  individual  case  must  be  guided  by  the  particular 
conditions  that  are  present ;  and,  if  only  we  bear  in  mind  the  natural 
history  of  the  hemorrhage,  we  may  confidently  expect  a  favorable 
termination. 

It  may  be  useful,  in  conclusion,  to  recapitulate  the  rules  which  have 
been  laid  down  for  treatment  in  the  form  of  a  series  of  propositions  : 

1.  Before  the  child  has  reached  a  viable  age,  temporize,  provided 
the  hemorrhage  be  not  excessive,  until  pregnancy  has  advanced  suffi- 
ciently to  afford  a  reasonable  hope  of  saving  the  child.     For  this 
purpose  the  chief  indication  is  absolute  rest  in  bed,  to  which  other 
accessory  means  of  preventing  hemorrhage,  such  as  cold,  etc.,  may  be 
added. 

2.  In  hemorrhage  occurring  after  the  seventh  month  of  utero-gesta- 
tion,  no  attempt  should  be  made  to  prolong  the  pregnancy. 

3.  In  all  cases  in  which  it  can  be  easily  effected,  the  membranes 
should  be  ruptured.     By  this  means  uterine  contractions  are  favored 
and  the  bleeding  vessels  compressed. 

4.  If  the  hemorrhage  be  stopped,  the  case  may  be  left  to  Nature. 

i  Obstet.  Operations,  2d  ed.,  p.  417. 


HEMORRHAGE    BEFORE    DELIVERY.  429 

If  flooding  continue,  and  the  os  be  not  sufficiently  dilated  to  admit  of 
the  labor  being  readily  terminated  by  turning,  the  os  and  the  vagina 
should  be  carefully  plugged,  Avhile  uterine  contractions  are  promoted 
by  abdominal  bandages,  uterine  compression,  and  ergot.  The  plug 
must  not  be  left  in  beyond  a  few  hours,  and  careful  antisepsis  should 
be  used. 

5.  If,  on  removal  of  the  plug,  the  os  be  sufficiently  expanded,  and 
the  general  condition  of  the  patient  be  good, -the  labor  may  be  ter- 
minated by  turning,  the  bi-polar  method  being  used  if  possible,  and 
the  lower  extremity  of  the  child  will  form  a  plug  until  delivery  is 
completed.     If  the  os  be  not  open  enough,  it  may  be  advantageously 
dilated  by  a  fluid  dilator  bag,  which  also  acts  as  a  plug. 

6.  Instead  of,  or  before  resorting  to,  turning,  the  placenta  may  be 
separated  around  the  site  of  its  attachment  to  the  cervix.     This  prac- 
tice is  specially  to  be  preferred  when  the  patient  is  much  exhausted 
and  in  a  condition  unfavorable  for  bearing  the  shock  of  turning. 

[Dr.  J.  Braxton  Hicks's  bimanual  method,  of  turning-,  as  tested 
in  Berlin  by  Drs.  Hofmeier,  Belira,  and  Lomer,  promises  much  better 
results  than  any  other  method  of  treatment  in  cases  of  placenta  pnevia. 
According  to  Dr.  Lomer's  report  in  the  Amer.  Journ.  of  Obstetrics  for 
December,  1884,  Dr.  Hofmeier  operated  upon  37  cases,  and  saved  36 
women  and  14  children ;  Drr  Behm,  upon  40  cases,  all_  saved,  but  lost 
31  children;  aud  he  himself,  with  eight  other  assistants,  upon  101  cases, 
saving  94,  with  50  children.  This  gives  8  deaths  of  women  and  105 
of  children  iu  178  cases,  or  a  mortality  of  4J  per  cent,  of  the  former 
and  60  per  cent,  of  the  latter.  Dr.  Lomer's  directions  are  as  follows : 
"  Turn  by  the  bimauual  method  as  soon  as  possible ;  pull  down  the 
leg,  and  tampon  with  it  aud  with  the  breech  of  the  child  the  ruptured 
vessels  of  the  placenta.  Do  not  extract  the  child  then;  let  it  come  by 
itself,  or  at  least  only  assist  its  natural  expulsion  by  gentle  and  rare 
tractions.  Do  away  with  the  plug  as  much  as  possible  ;  it  is  a  dan- 
gerous thing,  for  it  favors  infection  and  valuable  time  is  lost  with  its 
application.  Do  not  wait  in  order  to  perform  turning  until  the  cervix 
and  the  os  are  sufficiently  dilated  to  allow  the  hand  to  pass.  Turn 
as  soon  as  you  can  pass  one  or  two  fingers  through  the  cervix.  It  is 
unnecessary  to  force  your  fingers  through  the  cervix  for  this.  Intro- 
duce the  whole  hand  into  the  vagina,  pass  one  or  two  fingers  through 
the  cervix,  rupture  the  membranes,  and  turn  by  Braxton  Hicks's  bi- 
manual method."  .  .  .  "If  the  placenta  is  in  your  way,  try  to 
rupture  the  membranes  at  its  margin ;  but  if  this  is  not  feasible,  do 
not  lose  time ;  perforate  the  placenta  with  your  finger ;  get  hold  of  a 
leg  as  soon  as  possible,  and  bring  it  down." — ED.] 


430  LABOR. 


CHAPTER   XIV. 

HEMORRHAGE  FROM  SEPARATION  OF  A  NORMALLY  SITUATED 

PLACENTA. 

Definition. — This  is  the  f6rm  of  hemorrhage  which  is  generally 
described  in  obstetric  works  as  accidental,  in  contradistinction  to  the 
unavoidable  hemorrhage  of  placenta  prsevia.  In  discussing  the  latter 
we  have  seen  that  the  term  "accidental"  is  one  that  is  apt  to  mislead, 
and  that  the  causation  of  the  hemorrhage  in  placenta  pnevia  is,  in 
some  cases  at  least,  closely  allied  to  that  of  the  variety  of  hemorrhage 
we  are  now  considering. 

When,  from  any  cause,  separation  of  a  normally  situated  placenta 
occurs  before  delivery,  more  or  less  blood  is  necessarily  effused  from 
the  ruptured  utero-placental  vessels,  an/1  the  subsequent  course  of  the 
case  may  be  twofold :  1.  The  blood,  or  at  least  some  part  of  it,  may 
find  its  way  between  the  membranes  and  the  decidua,  and  escape  from 
the  os  uteri.  This  constitutes  the  typical  "accidental"  hemorrhage  of 
authors.  2.  The  blood  may  fail  to  find  a  passage  externally,  and  may 
collect  internally  (see  Plate  IV.),  giving  rise  to  very  serious  symptoms, 
and  even  proving  fatal,  before  the  true  nature  of  the  case  is  recognized. 
Cases  of  this  kind  are  by  no  means  so  rare  as  the  small  amount  of 
attention  paid  to  them  by  authors  might  lead  us  to  suppose ;  and,  from 
the  obscurity  of  the  symptoms  and  difficulty  of  diagnosis,  they  merit 
special  study.  Dr.  Goodell1  has  collected  no  less  than  106  instances 
in  which  this  complication  occurred. 

Causes  and  Pathology. — The  causes  of  placental  separation  may 
be  very  various.  In  a  large  number  of  cases  it  has  followed  an  acci- 
dent or  exertion  (such  as  slipping  down  stairs,  stretching,  lifting  heavy 
weights,  and  the  like)  which  has  probably  had  the  effect  of  lacerating 
some  of  the  placental  attachments.  At  other  times  it  has  occurred 
without  such  appreciable  cause,  and  then  it  has  been  referred  to  some 
change  in  the  uterus,  such  as  a  more  than  usually  strong  contraction 
producing  separation,  or  some  accidental  determination  of  blood  causing 
a  slight  extravasation  between  the  placenta  and  the  uterine  wall,  the 
irritation  of  which  leads  to  contraction  and  further  detachment.  Causes 
such  as  these,  which  are  of  frequent  occurrence,  Avill  not  produce  de- 
tachment except  in  women  otherwise  predisposed  to  it.  It  generally 
is  met  with  in  women  who  have  borne  many  children,  more  especially 
in  those  of  weakly  constitution  and  impaired  health,  and  rarely  in 
primiparse.  Certain  constitutional  states  probably  predispose  to  it, 
such  as  alburninuria  or  exaggerated  aiuemia ;  and,  still  more  so,  de- 
generations and  diseases  of  the  placenta  itself. 

i  Amer.  Journ.  of  Obstet.,  1S69-70,  vol.  ii.  p.  281. 


PLATE     IV. 


Blood-clot    1 


Placental  site 


_  I'lacental  site 


Placenta  attached 

r to  \yall  producing 

its  in  version 


Posterior  wall  of  uterus 


Retro-placental  blood-clot 


*    Anterior  wall 
it~     of  uterus 


Membranes 


•  Placenta 


VERTICAL   MESIAL  SECTION  OF  UTERUS  WITH   PLACENTA  PARTIALLY  ATTACHED- 
from  a  case  of  abdominal  section  for  heinorrhHge  during  labor.    After  BAHBOUK. 


(To  face  page  430.) 


HEMORRHAGE    BEFORE    DELIVERY.  431 

This  form  of  hemorrhage  rarely  occurs  to  an. alarming  extent  until 
the  later  months  of  pregnancy,  often  not  until  labor  has  commenced. 
The  great  size  of  the  placenta!  vessels  in  advanced  pregnancy  affords 
a  reasonable  explanation  of  this  fact. 

Symptoms  and  Diagnosis. — If,  after  separation  of  a  portion  of 
the  placenta,  the  blood  finds  its  way  between  the  membranes  and  the 
decidua,  its  escape  per  vaginam,  even  although  in  small  amount,  at 
once  attracts  attention,  and  reveals  the  nature  of  the  accident.  It  is 
otherwise  when  we  have  to  deal  with  a  case  of  concealed  hemorrhage, 
the  diagnosis  of  which  is  often  a  matter  of  difficulty.  Then  the  blood 
probably  at  first  collects  between  the  uterus  and  placenta.  Sometimes 
marginal  separation  does  not  occur,  and  large  blood-clots  are  formed 
in  this  situation,  and  retained  there.  More  often  the  margin  of  the 
placenta  separates,  and  the  blood  collects  between  the  membranes  and 
the  uterine  wall,  either  toward  the  cervix,  where  the  presenting  part 
of  the  child  may  prevent  its  escape,  or  near  the  fuudus.  In  the  latter 
case  especially,  the  coagula  are  apt  to  cause  very  painful  stretching 
and  distention  of  the  uterus.  The  blood  may  also  find  its  way  into 
the  amniotic  cavity,  but  more  frequently  it  does  not  do  so  ;  probably, 
as  Goodell  has  pointed  out,  because,  "should  the  os  uteri  be  closed, 
the  membranes,  however  delicate,  cannot,  other  things  being  equal, 
rupture  any  sooner  from  the  uterine  walls,  for  the  sum  of  the  resist- 
ance of  the  enclosed  liquor  amnii  being  equally  distributed  exactly 
counter-balances  the  sum  of  the  pressure  exerted  by  the  effusion." 
This  point  is  of  some  practical  importance,  because,  after  rupture  of 
the  membranes,  the  liquor  amnii  is  frequently  found  untinged  with 
blood,  and  this  might  lead  us  to  suppose  ourselves  mistaken  in  our 
diagnosis,  if  this  fact  were  not  borne  in  mind. 

The  most  prominent  symptoms  in  concealed  internal  hemorrhage 
are  extreme  collapse  and  exhaustion,  for  which  no  adequate  cause  can 
be  assigned.  These  differ  from  those  of  ordinary  syncope,  with  which 
they  might  be  confounded,  chiefly  in  their  persistence  and  severity, 
and  in  the  presence  of  the  symptoms  attending  severe  loss  of  blood, 
such  as  coldness  and  pallor  of  the  surface,  great  restlessness  and 
anxiety,  rapid  and  sighing  respiration,  yawning,  feeble,  quick,  and 
compressible  pulse.  When  there  is  severe  internal,  with  slight  exter- 
nal, hemorrhage,  we  may  be  led  to  a  proper  diagnosis  by  observing 
that  the  constitutional  symptoms  are  much  more  severe  than  the 
a n ion nt  of  external  hemorrhage  would  account  for.  Uterine  pain  is 
generally  present,  of  a  tearing  and  stretching  character,  sometimes 
moderate  in  amount,  more  often  severe,  and  occasionally  amounting  to 
intolerable  anguish.  It  is  often  localized,  and,  doubtless,  depends  on 
the  distention  of  the  uterus  by  the  retained  coagula.  If  the  disten- 
tion be  marked,  there  may  be  an  irregularity  in  the  form  of  the  utcni- 
at  the  site  of  sanguineous  effusion  ;  but  this  will  be  difficult  to  make 
out,  except  in  women  with  thin  and  unusually  lax  abdominal  parietes. 
A  rapid  increase  in  the  size  of  the  uterus  has  been  described  as  a  sign 
by  ( 'a/caux  and  others.  It  is  not  very  likely  that  this  will  be  appre- 
ciable toward  the  end  of  utero-gestation,  as  a  very  large  amount  of 
effusion  would  be  necessary  to  produce  it.  At  an  earlier  period  of 


432  LABOR. 

pregnancy,  at  or  about  the  fifth  month,  I  made  it  out  very  distinctly 
in  a  case  in  my  own  practice.  It  obviously  must  have  occurred  to  an 
enormous  extent  in  a  case  related  by  Chevalier,  in  which  post-mortem 
Cfesarean  section  was  performed  under  the  impression  that  the  preg- 
nancy had  advanced  to  term,  but  only  a  three  months'  fetus  was  found, 
imbedded  in  coagula  which  distended  the  uterus  to  the  size  of  a  nine 
months'  gestation.1  Labor  pains  may  be  entirely  absent.  If  present, 
they  are  generally  feeble,  irregular,  and  inefficient. 

Differential  Diagnosis. — The  only  condition,  beside  ordinary  syn- 
cope, likely  to  be  confounded  with  this  form  of  hemorrhage,  is  rupture 
of  the  uterus,  to  which  the  intense  pain  and  profound  collapse  induce 
considerable  resemblance.  The  latter  rarely  occurs  until  after  labor 
has  been  some  time  in  progress,  and  after  the  escape  of  the  liquor 
amnii ;  whereas  hemorrhage  usually  occurs  either  before  labor  has 
commenced,  or  at  an  early  stage.  The  recession  of  the  presentation, 
and  the  escape  of  the  foetus  into  the  abdominal  cavity,  in  cases  of  rup- 
ture, will  further  aid  in  establishing  the  diagnosis. 

Prognosis. — The  prognosis,  when  blood  escapes  externally,  is,  on 
the  whole,  not  unfavorable.  The  nature  of  the  case  is  apparent,  and 
remedial  measures  are  generally  adopted  sufficiently  early  to  prevent 
serious  mischief.  It  is  different  with  the  concealed  form,  in  which 
the  mortality  is  very  great.  Out  of  Goodell's  106  cases,  no  less  than 
fifty-four  mothers  died.  This  excessive  death-rate  is,  no  doubt,  partly 
due  to  the  fact  that  extreme  prostration  often  occurs  before  the  exist- 
ence of  hemorrhage  is  suspected,  and  partly  to  the  accident  generally 
happening  in  women  of  weakly  and  diseased  constitution.  The  prog- 
nosis to  the  child  is  still  more  grave.  Out  of  107  children,  only  six 
were  born  alive.  The  almost  certain  death  of  the  child  may  be  ex- 
plained by  the  fact  that,  when  blood  collects  between  the  uterus  and 
the  placenta,  the  foetal  portion  of  the  latter  is  probably  lacerated,  and 
the  child  then  also  dies  from  hemorrhage. 

Treatment. — In  this,  as  in  all  other  forms  of  puerperal  hemor- 
rhage, the  great  haemostatic  is  uterine  contraction,  and  that  we  must 
try  to  encourage  by  all  possible  means.  The  first  thing  to  be  done, 
whether  the  hemorrhage  be  apparent  or  concealed,  is  to  rupture  the 
membranes.  If  the  loss  of  blood  be  only  slight,  this  may  suffice  to 
control  it,  and  the  case  may  then  be  left  to'  Nature.  A  firm  abdominal 
binder  should,  however,  be  applied  to  prevent  any  risk  of  blood  col- 
lecting internally,  as  there  is  nothing  to  prevent  its  tilling  the  uterine 
cavity  after  the  membranes  are  ruptured.  Contraction  may  be  further 
advantageously  solicited  by  uterine  compression,  and  by  the  adminis- 
tration of  full  doses  of  ergot.  If  hemorrhage  continue^  or  if  we  have 
any  reason  to  suspect  concealed  hemorrhage,  the  sooner  the  uterus  is 
emptied  the  better.  If  the  os  be  sufficiently  dilated,  the  best  practice 
will  be  to  turn  without  further  delay,  using  the  bi-polar  method  if 
possible.  If  the  os  be  not  open  enough,  a  Barnes  bag  should  be  in- 
troduced, while  firm  pressure  is  kept  up  to  prevent  uterine  accumula- 
tion. Should  the  collapsed  condition  of  the  patient  be  very  marked, 

1  Journ.  de  Med.  Clin.  et  Pbarm.,  torn.  xxi.  p.  363. 


HEMORRHAGE    AFTER    DELIVERY.  433 

the  mere  shock  of  the  operation  might  turn  the  scale  against  her. 
Under  such  circumstances  it  may  be  better  practice  to  delay  further 
procedure  until,  by  the  administration  of  stimulants,  warmth,  etc.,  we 
have  succeeded  in  producing  some  amount  of  reaction,  keeping  up,  in 
the  meanwhile,  firm  pressure  on  the  uterus.  Should  the  head  be  low 
down  in  the  pelvis,  it  may  be  easier  to  complete  labor  by  means  of  the 
forceps. 


CHAPTER   XV. 

• 

HEMORRHAGE  AFTER  DELIVERY. 

Its  Importance. — Hemorrhage  during,  or  shortly  after,  the  third 
stage  of  labor  is  one  of  the  most  trying  and  dangerous  accidents  con- 
nected with  parturition.  Its  sudden  and  unexpected  occurrence  just 
after  the  labor  appears  to  be  happily  terminated,  and  its  alarming 
effect  on  the  patient,  who  is  often  placed  in  the  utmost  danger  in  a  few 
moments,  tax  the  presence  of  mind  and  the  resources  of  the  practi- 
tioner to  the  utmost,  and  render  it  an  imperative  duty  on  everyone 
who  practises  midwifery  to  make  himself  thoroughly  acquainted  with 
its  causes,  and  preventive  and  curative  treatment.  There  is  no  emer- 
gency in  obstetrics  which  leaves  less  time  for  reflection  and  consulta- 
tion, and  the  life  of  the  patient  will  often  depend  on  the  prompt  and 
immediate  action  of  the  medical  attendant. 

Frequency  of  Post-partum  Hemorrhage. — Post-partum  hemor- 
rhage is  one  of  the  most  frequent  complications  of  delivery.  I  do  not 
know  of  any  statistics  which  enable  us  to  judge  with  accuracy  of  its 
frequency,  but  I  believe  it  to  be  an  unquestionable  fact  that,  especially 
in  the .  upper  ranks  of  society,  it  is  very  common  indeed.  This  is 
probably  due  to  the  effects  of  civilization,  and  to  the  mode  of  life  of 
patients  of  that  class,  whose  whole  surroundings  tend  to  produce  a 
lax  habit  of  body  which  favors  uterine  inertia,  the  principal  cause  of 
post-partum  hemorrhage.  In  the  report  of  the  Registrar-General  for 
the  five  years  from  1872  to  1876,  3524  deaths  are  attributed  to  flood- 
ing. The  majority  of  these  must  have  been  caused  by  post-partum 
hemorrhage,  although  some  may  have  been  from  other  forms. 

Fortunately,  it  is,  to  a  great  extent,  a  preventable  accident.  I 
believe  this  fact  cannot  be  too  strongly  impressed  on  the  practitioner. 
If  the  third  stage  of  labor  be  properly  conducted,  if  every  case  be 
treated,  as  every  case  ought  to  be,  as  if  hemorrhage  were  impending, 
it  would  be  much  more  infrequent  than  it  is.  It  is  a  curious  fact 
that  post-partum  hemorrhage  is  much  more  common  in  the  practice  of 
some  medical  men  than  in  that  of  others  ;  the  reason  being  that  those 
who  meet  with  it  often,  are  careless  in  their  management  of  their 

28 


434  LABOR. 

patients  immediately  after  the  birth  of  the  child.  That  is  just  the 
time  when  the  assistance  of  a  properly  qualified  practitioner  is  of 
value,  much  more  so  than  before  the  second  stage  of  labor  is  con- 
cluded; hence,  when  I  hear  that  a  medical  man  is  constantly  meeting 
with  severe  post-partum  hemorrhage,  I  hold  myself  justified,  ipso 
facto,  in  inferring  that  he  does  not  know,  or  does  not  practice,  the 
proper  mode  of  managing  the  third  stage  of  labor. 

Causes. — The  placenta,  as  we  have  seen,  is  separated  by  the  last 
pains,  and  the  blood,  which  in  greater  or  less  quantity  accompanies 
the  foetus,  probably  comes  from  the  utero-placental  vessels  which  are 
then  lacerated.  Almost  immediately  afterward  the  uterus  contracts 
firmly,  and,  in  a  typical  labor,  assumes  the  hard  cricket-ball  form 
which  is  so  comforting  to  the  accoucheur  to  feel.  (See  Plate  V.) 
The  result  is  the  compression  of  all  of  the  vascular  trunks  which 
ramifv  in  its  walls,  both  arteries  and  veins,  and  thus  the  flow  of  blood 
through  them  is  prevented.  By  referring  to  what  has  been  said  as  to 
the  anatomy  of  the  muscular  fibres  of  the  gravid  uterus,  especially  at 
the  placental  site  (p.  62),  it  will  be  seen  how  admirably  they  are 
adapted  for  this  purpose.  The  arrangement  of  the  vessels  themselves 
favors  the  hamostatic  action  of  uterine  contraction.  The  large  venous 
sinuses  are  placed  in  layers  one  above  the  other,  in  the  thickness  of 
the  uterine  walls,  and  they  anastomose  freely.  When  the  superim- 
posed layers  communicate  with  those  immediately  below  them,  the 
junction  is  by  a  falciform  or  semilunar  opening  in  the  floor  of  the 
vessel  nearest  the  external  surface  of  the  uterus.  Within  the  margins 
of  this  aperture  there  are  muscular  fibres,  the  contraction  of  which 
probably  tends  to  prevent  retrogression  of  blood  from  one  layer  of 
vessels  into  the  other.  The  venous  sinuses  themselves  are  of  a  flattened 
form,  and  they  are  intimately  attached  to  the  muscular  tissues.  It  is 
obvious,  then,  that  these  anatomical  arrangements  are  eminently 
adapted  to  facilitate  the  closure  of  the  vessels.  They  are,  however, 
large,  and  are  destitute  of  valves ;  and  if  contraction  be  absent,  or  if 
it  be  partial  and  irregular,  it  is  equally  easy  to  understand  why  blood 
should  pour  forth  in  the  appalling  amount  which  is  sometimes 
observed. 

If  uterine  action  be  firm,  regular,  and  continuous,  the  vessels  must 
be  sealed  up  and  hemorrhage  eifectually  prevented.  This  fact  has 
been  doubted  by  many  authorities.  Gooch  was  the  first  to  describe 
what  he  called  "a  peculiar  form  of  hemorrhage"  accompanying  a 
contracted  womb.  Similar  observations  have  been  made  by  other 
writers;  such  as  Velpeau,  Rigby,  and  Gendriu.  Simpson  says,  on  this 
point,  that  strong  uterine  contractions  "are  not  probably  so  essential 
a  part  in  the  mechanism  of  the  prevention  of  hemorrhage  from  the 
open  orifices  of  the  uterine  veins  as  we  might  a  priori  suppose."1 
With  regard  to  Gooch's  cases,  it  has  been  pointed  out  that  his  own 
description  proves  that,  however  firmly  the  uterus  may  have  contracted 
immediately  after  the  expulsion  of  the  child,  it  must  have  subse- 
quently relaxed,  for  he  passed  his  hand  into  it  to  remove  retained 

1  Selected  Obstetric  Works,  p.  234. 


HEMORRHAGE    AFTER    DELIVERY.  435 

clots,  a  manoeuvre  which  he  could  not  have  practised  had  tonic  con- 
traction been  present.  In  some  of  these  cases  the  hemorrhage  has 
been  found  to  come  from  a  laceration  of  the  cervix.  Of  course,  blood 
may  readily  escape  from  a  mechanical  injury  of  this  kind,  although 
the  uterus  itself  be  in  a  satisfactory  state  of  contraction ;  and  the  pos- 
sibility of  this  occurrence  should  always  be  borne  in  mind.  Instances 
of  the  successful  treatment  of  this  variety  of  post-part  um  hemorrhage 
by  sutures  applied  to  the  lacerated  cervix  have  been  related  by  Fallen 
and  others. 

Although,  then,  we  may  admit  that  post-partum  hemorrhage  is  in- 
compatible with  persistent  contraction  of  the  uterus,  it  by  no  means 
follows  that  the  converse  is  true.  On  the  contrary,  it  is  not  uncom- 
mon to  meet  with  cases  in  which  the  uterus  is  large,  and  apparently 
quite  flaccid,  and  in  which  there  is  no  loss  of  blood.  Alternate  relaxa- 
tion and  contraction  of  the  uterus  after  delivery  are  also  of  constant 
occurrence,  and  yet  hemorrhage,  during  the  relaxation,  does  not  take 
place.  The  explanation  no  doubt  is,  that  immediately  after  the  birth 
of  the  child  there  was  sufficient  contraction  to  prevent  hemorrhage, 
and  that,  during  its  continuance,  coagula  formed  in  the  mouths  of  the 
uterine  sinuses,  by  which  they  were  sufficiently  occluded  to  prevent 
any  loss  when  subsequent  relaxation  occurred. 

In  all  probability  both  uterine  contraction  and  thrombosis  are  in 
operation  in  ordinary  cases ;  and  we  shall  presently  see  that  all  the 
means  employed  in  the  treatment  of  post-partum  hemorrhage  act  by 
producing  one  or  other  of  them. 

Uterine  inertia  after  labor,  then,  may  be  regarded  as  the  one  great 
primary  cause  of  post-partum  hemorrhage ;  but  there  are  various  sec- 
ondary causes  which  tend  to  produce  it,  one  of  the  most  frequent  of 
which  is  exhaustion  following  a  protracted  labor.  The  uterus  gets 
worn  out  by  its  efforts,  and  when  the  foetus  is  expelled,  it  remains  in 
a  relaxed  state,  and  hemorrhage  results.  Over-distention  of  the  uterus 
acts  in  the  same  way.  Hence  hemorrhage  is  very  frequently  met  with 
when  there  has  been  an  excessive  amount  of  liquor  amnii,  or  in  mul- 
tiple pregnancies.  One  of  the  worst  cases  I  ever  met  with  was  after 
the  birth  of  triplets,  the  uterus  having  been  of  an  enormous  size. 
Rapid  emptying  of  the  uterus,  during  which  there  has  not  been  suffi- 
cient time  for  complete  separation  of  the  placenta,  often  'tends  to  the 
same  result.  This  is  the  reason  why  hemorrhage  so  frequently  follows 
forceps  delivery,  especially  if  the  operation  have  been  unduly  hur- 
ried ;  and  it  is  one  of  the  chief  dangers  in  what  are  termed  "precipi- 
tate labors."  The  general  condition  of  the  patient  may  also  strongly 
predispose  to  it.  Thus  it  is  more  often  met  with  in  women  who  have 
borne  families,  especially  if  they  be  weakly  in  constitution,  compara- 
tively seldom  in  primiparee ;  and  for  the  same  reason  that  after-pains 
are  most  common  in  the  former,  namely,  that  the  uterus,  weakened  by 
frequent  childbearing,  contracts  inefficiently.  The  experience  of  prac- 
titioners in  the  tropics  shows  that  European  women,  debilitated  by 
the  relaxing  effects  of  warm  climates,  are  peculiarly  prone  to  it,  and 
it  forms  one  of  the  chief  dangers  of  childbirth  amongst  the  English 
ladies  in  India. 


436 


LABOR. 


Another  important  cause  of  post-partum  hemorrhage  is  partial  and 
irregular  contraction  of  the  uterus.  Part  of  the  muscular  tissue  is 
firmly  contracted,  while  another  part  is  relaxed,  and  the  latter  very 
often  the  placental  site.  This  has  been  especially  dwelt  on  by  Simp- 
son. He  says:  "The  morbid  condition  which  is  most  frequently  and 
earliest  seen  in  connection  with  post-partum  hemorrhage,  is  a  state  of 
irregularity  and  want  of  equability  in  the  contractile  action  of  different 
parts  of  the  uterus — and,  it  may  be,  in  different  planes  of  the  mus- 
cular fibres — as  marked  by  one  or  more  points  in  the  organ  feeling 
hard  and  contracted,  at  the  same  time  that  other  portions  of  the 
parietes  are  soft  and  relaxed." 

One  peculiar  variety,  which  has  been  much  dwelt  on  by  writers, 
and  is  a  prominent  bugbear  to  obstetricians,  is  the  so-called  hour-glass 
contraction.  This  in  reality  seems  to  depend  on  spasmodic  contraction 
of  the  internal  os  uteri,  by  means  of  which  the  placenta  becomes 
encysted  in  the  upper  portion  of  the  uterus,  which  is  relaxed.  On 
introducing  the  hand,  it  first  passes  through  the  lax  cervical  canal 
until  it  comes  to  the  closed  internal  os,  with  the  umbilical  cord  passing 
through  it,  which  has  generally  been  supposed  to  be  a  circular  con- 
traction of  a  portion  of  the  body  of  the  uterus. 

Encystment  of  the  placenta,  however,  although  more  rarely,  unques- 
tionably takes  place  in  a  portion  only  of  the  body  of  the  uterus 
(Fig.  153).  Then  apparently  the  placeutal  site  remains  more  or  less 

FIG.  153. 


Irregular  contraction  of  the  uterus,  with  encystment  of  the  placenta. 


paralyzed,  with  the  placenta  still  attached,  while  the  remainder  of  the 
body  of  the  uterus  contracts  firmly,  and  thus  encystment  is  produced. 

These  irregular  contractions  of  the  uterus  are  by  no  means  so  common 
as  our  older  authors  supposed.  When  they  do 'occur,  I  believe  them 
almost  invariably  to  depend  on  defective  management  of  the  third 
stage  of  ^labor.  "  The  most  frequent  cause,"  says  Kigby,1  "  is  from 
over-anxiety  to  remove  the  placenta ;  the  cord  is  frequently  pulled  at, 

1  Rigby's  Midwifery,  p.  225. 


HEMORRHAGE    AFTER    DELIVERY.  437 

and  at  length  the  'os  uteri  is  excited  to  contract."  While  this  is  being 
done,  no  attempts  are  probably  being  made  to  excite  the  fundus  to 
proper  action,  and,  therefore,  the  hour-glass  contraction  is  established. 
Johnstoue1  has  pointed  out  that  in  a  large  proportion  of  cases  ergot 
has  been  given  before  the  expulsion  of  the  placenta.  Duncan  says  of 
this  condition  :  "  Hour-glass  contraction  cannot  exist  unless  the  parts 
above  the  contraction  are  in  a  state  of  inertia ;  were  the  higher  parts 
of  the  uterus  even  in  moderate  action,  the  hour-glass  contraction  would 
soon  be  overcome."2  If  placeutal  expression  were  always  employed,  if 
it  were  the  rule  to  effect  the  expulsion  of  the  placenta  by  a  vis  a  tergo, 
instead  of  extracting  it  by  a  vis  a  fronte,  I  feel  confident  that  these 
irregular  and  spasmodic  contractions — of  the  influence  of  which  in 
producing  hemorrhage  there  can  be  no  question — would  rarely,  if  ever, 
be  met  with.  It  is  to  be  observed  that,  even  in  these  cases,  it  is  not 
because  the  uterus  is  in  a  state  of  partial  contraction,  but  because  it  is 
in  a  state  of  partial  relaxation,  that  hemorrhage  ensues. 

Placental  Adhesions. — Adhesions  of  the  placenta  to  the  uterine 
parietes  may  cause  hemorrhage,  especially  if  they  be  partial  and  the 
remainder  of  the  placenta  be  detached.  The  frequency  of  these  has 
been  over-estimated.  Many  cases  believed  to  be  examples  of  adherent 
placentae  are,  in  reality,  only  cases  of  placentae  retained  from  uterine 
inertia.  The  experience  of  all  who  see  much  midwifery  will  probably 
corroborate  the  observation  of  Braun,  that  "  abnormal  adhesion  and 
hour-glass  contraction  are  more  frequently  encountered  in  the  expe- 
rience of  the  young  practitioner,  and  they  diminish  in  frequency  in 
direct  ratio  to  increasing  years."3  The  cause  of  adhesion  is  often 
obscure,  but  it  most  probably  results  from  a  morbid  state  of  the 
decidua,  which  is  produced  by  antecedent  disease  of  the  uterine  mucous 
membrane ;  then  the  adhesion  is  apt  to  recur  in  subsequent  pregnancies. 
The  decidua  is  altered  and  thickened,  and  patches  of  calcareous  and 
fibrous  degeneration  may  be  often  found  on  the  attached  surface  of  the 
placenta.  Most  frequently  the  placenta  is  only  partially  adherent; 
patches  of  it  remain  firmly  attached  to  the  uterus,  while  the  rest  is 
separated;  hence  the  uterine  walls  remain  relaxed  and  hemorrhage 
frequently  follows.  The  diagnosis  and  management  of  these  very 
troublesome  cases  will  be  found  described  under  the  head  of  treatment 
(p.  441). 

Finally,  I  think  it  must  be  admitted  that  there  are  some  women 
who  really  merit  the  appellation  of  "  Flooders"  which  has  been  applied 
to  them,  and  who,  do  what  we  may,  have  the  most  extraordinary  ten- 
dency to  hemorrhage  after  delivery.  I  do  not  think  that  these  cases, 
however,  are  by  any  means  so  common  as  some  have  supposed.  I  have 
attended  several  patients  who  have  nearly  lost  their  lives  from  post- 
partum  hemorrhage  in  former  labors,  some  who  have  suffered  from  it 
in  every  preceding  confinement,  and  I  have  only  met  with  two  cases 
in  which  the  assiduous  use  of  preventive  treatment  failed  to  avert  it. 
In  these  (one  of  which  I  have  elsewhere  published  in  detail4),  in  spite 

1  Glasgow  Med.  Journ.,  1887,  vol.  xxvii.  p.  188. 

2  Researches  in  Obstetrics,  p.  389.  *  Braun's  Lectures,  1869. 
«  Obst.  Jouru.,  1873-74,  vol.  i.  p.  89. 


438  LABOR. 

of  all  my  efforts,  I  could  not  succeed  in  keeping  up  uterine  contraction, 
and  the  patients  would  certainly  have  lost  their  lives  were  it  not  for 
the  means  which  modern  improvements  have  fortunately  placed  at  our 
disposal  for  producing  thrombosis  in  the  mouths  of  the  bleeding 
vessels.  The  nature  of  these  rare  cases  requires  further  investigation  ; 
possibly  they  may,  to  some  extent,  be  the  subjects  of  the  so-called 
hemorrhagic  diathesis. 

The  loss  of  blood  may  commence  immediately  after  the  birth  of  the 
child,  before  the  expulsion  of  the  placenta,  or  not  until  some  time 
afterward,  when  the  contracted  uterus  has  again  relaxed.  It  may 
commence  gradually  or  suddenly ;  in  the  latter  case  it  may  begin  with 
a  gush,  and  in  the  worst  form  the  bedclothes,  the  bed,  and  even  the 
floor,  are  deluged  with  the  blood  which,  it  is  no  exaggeration  to  say, 
is  pouring  from  the  patient.  If  now  the  hand  be  placed  on  the  abdo- 
men, we  shall  miss  the  hard  round  ball  of  the  contracted  uterus,  which 
will  be  found  soft  and  flabby,  or  we  may  even  be  unable  to  make  out 
its  contour  at  all.  If  the  hemorrhage  be  slight,  or  if  we  succeed  in 
controlling  it  at  once,  no  serious  consequences  follow ;  but  if  it  be  ex- 
cessive, or  if  we  fail  to  check  it,  the  gravest  results  ensue. 

There  are  few  sights  more  appalling  to  witness  than  one  of  the  worst 
cases  of  post-partum  hemorrhage.  The  pulse  becomes  rapidly  affected, 
and  may  be  reduced  to  a  mere  thread,  or  it  may  become  entirely  im- 
perceptible. Syncope  often  comes  on — not  in  itself  always  an  un- 
favorable occurrence,  as  it  tends  to  promote  thrombosis  in  the  venous 
sinuses.  Or,  short  of  actual  syncope,  there  may  be  a  feeling  of  intense 
debility  and  faintness.  Extreme  restlessness  soon  supervenes,  the 
patient  throws  herself  about  the  bed,  tossing  her  arms  wildly  above 
her  head ;  respiration  becomes  gasping  and  sighing,  the  u  besoin  de 
respirer"  is  acutely  felt,  and  the  patient  cries  out  for  more  air ;  the  skin 
becomes  deadly  cold,  and  covered  with  profuse  perspiration ;  if  the 
hemorrhage  continue  unchecked,  we  next  may  have  complete  loss  of 
vision,  jactitation,  convulsions,  and  death. 

Formidable  as  such  symptoms  are,  it  is  satisfactory  to  know  that 
recovery  often  takes  place,  even  when  the  powers  of  life  seem  reduced 
to  the  lowest  ebb.  If  we  can  check  the  hemorrhage  while  there  is 
still  some  power  of  reaction  left,  however  slight,  we  may  not  unreason- 
ably hope  for  eventual  recovery.  The  constitution,  however,  may 
have  received  a  severe  shock,  and  it  may  be  months,  or  even  years, 
before  the  patient  recovers  from  the  effects  of  only  a  few  minutes' 
hemorrhage.  A  death-like  pallor  frequently  follows  these  excessive 
losses,  and  the  patient  often  remains  blanched  and  exsanguine  for  a 
long  time. 

Preventive  Treatment. — The  preventive  treatment  of  post-partum 
hemorrhage  should  be  carefully  practised  in  every  case  of  labor,  how- 
ever normal.  If  the  practitioner  make  a  habit  of  never  removing  his 
hand  from  the  uterus  after  the  birth  of  the  child  until  the  placenta  is 
expelled,  and  of  keeping  up  continuous  uterine  contraction  for  at  least 
half  an  hour  after  delivery  is  completed,  not  necessarily  by  friction  on 
the  fundus,  but  by  simply  grasping  the  contracted  womb  with  the 
palm  of  the  hand  and  preventing  its  undue  relaxation,  cases  of  post- 


HEMORRHAGE    AFTER    DELIVERY.  439 

partum  flooding  will  seldom  be  met  with.  As  a  rule  we  should  not,  I 
think,  apply  the  binder  until  at  least  that  time  has  elapsed.  The 
binder  is  an  effective  means  of  keeping  up,  but  not  of  producing,  con- 
traction, and  it  should  never  be  trusted  to  for  the  latter  purpose.  If 
it  be  put  on  too  soon,  the  uterus  may  relax  under  it,  and  become  filled 
with  clots  without  the  practitioner  knowing  anything  about  it ;  whereas, 
this  cannot  possibly  take  place  as  long  as  the  uterine  globe  is  held  in 
the  hollow  of  the  hand.  I  have  seen  more  than  one  serious  case  of 
concealed  hemorrhage  result  from  the  too  common  habit  of  putting  on 
the  binder  immediately  after  the  removal  of  the  placenta.  I  believe 
also,  as  I  have  formerly  said,  that  it  is  thoroughly  good  practice  to 
administer  a  full  dose  of  the  liquid  extract  of  ergot  in  all  cases  after 
the  placenta  has  been  expelled,  to  insure  persistent  contraction  and  to 
lessen  the  chance  of  blood-clots  being  retained  in  utero. 

These  are  the  precautions  which  should  be  used  in  all  cases  alike ; 
but  when  we  have  reason  to  fear  the  occurrence  of  hemorrhage,  from 
the  history  of  previous  labors  or  other  cause,  special  care  should  be 
taken.  The  ergot  should  be  given,  and  preferably  in  the  form  of  the 
subcutaneous  injection  of  ergotine,  before  the  birth  of  the  child,  when 
the  presentation  is  so  far  advanced  that  we  estimate  that  labor  will  be 
concluded  in  from  ten  to  twenty  minutes,  as  we  can  hardly  expect  the 
drug  to  produce  any  eifect  in  less  time.  Particular  attention,  more- 
over, should  then  be  paid  to  the  state  of  the  uterus.  Every  means 
should  be  taken  to  insure  regular  and  strong  contraction,  and  it  is 
advisable  to  rupture  the  membranes  early,  as  soon  as  the  os  is  dilated 
or  dilatable,  to  insure  stronger  uterine  action.  If  any  tendency  to 
relaxation  occur  after  delivery,  a  piece  of  ice  should  be  passed  into  the 
vagina  or  into  the  uterus.  Should  coagula  collect  in  the  uterus,  they 
may  be  readily  expelled  by  firm  pressure  on  the  fundus,  and  the  finger 
should  be  passed  occasionally  up  to  the  cervix,  and  any  which  are  felt 
there  should  be  gently  picked  away. 

We  should  be  specially  on  our  guard  in  all  cases  in  which  the  pulse 
does  not  fall  after  delivery.  If  it  beat  at  100  or  more  some  ten  rhinutes 
or  a  quarter  of  an  hour  after  the  birth  of  the  child,  hemorrhage  not 
unfrequently  follows  ;  and  hence  it  is  a  good  practical  rule,  which  may 
save  much  trouble,  that  a  patient  should  never  be  left  unless  the  pulse 
has  fallen  to  its  natural  standard. 

Curative  Treatment. — As  there  are  only  two  means  which  Nature 
adopts  in  the  prevention  of  post-partum  hemorrhage,  so  the  remedial 
measures  also  may  be  divided  into  two  classes  :  1.  Those  which  act 
by  the  production  of  uterine  contraction.  2.  Those  which  act  by  pro- 
ducing thrombosis  in  the  vessels.  Of  these  the  first  are  the  most 
commonly  used ;  and  it  is  only  in  the  worst  cases,  in  which  they  have 
been  assiduously  tried  and  have  failed,  that  we  resort  to  those  coming 
under  the  second  heading. 

The  patient  should  be  placed  on  her  back,  in  which  position  we  can 
more  readily  command  the  uterus,  as  well  as  attend  to  her  general 
state.  If  the  uterus  be  found  relaxed  and  full  of  clots,  by  firmly 
grasping  it  in  the  hand  contraction  may  be  evoked,  its  contents  ex- 
pelled, and  further  hemorrhage  at  once  arrested.  Should  this  fortu- 


440  LABOR. 

nately  be  the  case,  we  must  keep  up  contraction  by  gently  kneading 
the  uterus,  until  we  are  satisfied  that  undue  relaxation  will  not  recur. 

The  powerful  influence  of  friction  in  promoting  contraction  cannot 
be  doubted,  and  nothing  will  replace  it ;  no  doubt  it  is  fatiguing,  but 
as  long  as  it  is  effectual  it  must  be  kept  up.  No  roughness  should  be 
used,  as  we  might  produce  subsequent  injury,  but  it  is  quite  possible  to 
use  considerable  pressure  without  any  violence. 

Another  method  of  applying  uterine  pressure  has  been  strongly 
advocated  by  Dr.  Hamilton,  of  Falkirk,  and  it  may  be  serviceable 
where  there'  is  a  constant  draining  from  the  uterus,  and  a  capacious 
pelvis.  It  consists  in  passing  the  fingers  of  the  right  hand  high  up 
into  the  posterior  cul-de-sac  of  the  vagina,  so  as  to  reach  the  posterior 
surface  of  the  uterus,  while  counter-pressure  is  exercised  by  the  left 
hand  through  the  abdomen.  The  anterior  and  posterior  Avails  of  the 
uterus  are  thus  closely  pressed  together. 

During  the  time  that  pressure  is  being  applied,  attention  can  be  paid 
to  general  treatment ;  and  in  giving  his  directions  to  the  bystanders 
the  practitioner  should  be  calm  and  collected,  avoiding  all  hurry  and 
excitement,  A  full  dose  of  ergot  should  be  administered,  and  if  one 
have  already  been  given,  it  should  be  repeated.  We  cannot,  however, 
look  upon  ergot  as  anything  but  a  useful  accessory,  and  it  is  one  which 
requires  considerable  time  to  operate.  The  hypodermic  use  of  ergotine 
offers  the  double  advantage,  in  severe  cases,  of  acting  with  greater 
power,  and  much  more  rapidly,  than  the  usual  method  of  administra- 
tion. It  should,  therefore,  always  be  used  in  preference.  An  aqueous 
solution  of  ergotinine,  YTJTJ-  of  a  grain  in  10  minims,  has  been  highly 
recommended  by  Chahbazain,  of  Paris,  as  acting  more  energetically, 
and,  it  has  seemed  to  me,1  has  had  a  good  effect. 

The  sudden  flow  will  probably  have  produced  exhaustion  and  a 
tendency  to  syncope,  and  the  administration  of  stimulants  will  be 
necessary.  The  amount  must  be  regulated  by  the  state  of  the  pulse 
and  the  degree  of  exhaustion.  There  is  no  more  absurd  mistake,  how- 
ever, than  implicitly  relying  on  the  brandy  bottle  to  check  post-partum 
hemorrhage.  In  the  worst  cases  absorption  is  in  abeyance,  and  brandy 
may  be  poured  down  in  abundance,  the  practitioner  believing  that  he 
is  rousing  his  patient,  while  he  is,  in  fact,  only  filling  the  stomach  with 
a  quantity  of  fluid  which  is  eventually  thrown  up  unaltered.  I  have 
more  than  once  seen  symptoms,  produced  by  the  over-free  use  of  brandy 
in  slight  floodings,  which  were  certainly  not  those  of  hemorrhage.  I 
remember  on  one  occasion  being  summoned  by  a  practitioner,  with 
a  view  to  transfusion,  to  a  patient  who  was  said  to  be  insensible  and 
collapsed  from  hemorrhage.  I  found  her,  indeed,  unconscious;  but 
with  a  flushed  face,  a  bounding  pulse,  a  firmly  contracted  uterus,  and 
deep  stertorous  breathing.  On  inquiry  I  ascertained  that  she  had 
taken  an  enormous  quantity  of  brandy,  which  had  brought  on  the 
coma  of  profound  intoxication,  while  the  hemorrhage  had  obviously 
never  been  excessive. 

The  hypodermic  injection  of  sulphuric  ether  is  a  remedy  of  great 

1  Obst.  Trans,  for  1882,  vol.  xxiv.  p.  286. 


HEMORRHAGE    AFTER    DELIVERY.  441 

value  as  a  powerful  stimulant  in  cases  in  which  exhaustion  is  very- 
great.  It  has  the  advantage  of  acting  rapidly,  and  of  being  capable 
of  administration  when  the  patient  is  unable  to  swallow.  A  fluid 
drachm  may  be  injected  into  the  nates,  or  thigh,  and  the  injection  may 
be  repeated  as  the  state  of  the  patient  may  require. 

The  window  should  be  thrown  widely  open,  to  allow  a  current  of 
fresh  cold  air  to  circulate  freely  through  the  room.  The  pillows  should 
be  removed,  the  head  kept  low,  and  the  patient  should  be  assiduously 
fanned.  It  is  often  found  to  be  useful  to  raise  the  feet  of  the  bed  on 
blocks  of  wood,  or  books,  so  as  to  have  the  head  lower  than  the  pelvis. 
This  will  favor  the  current  of  blood  to  the  head,  and  lessen  the  ten- 
dency to  syncope. 

If  bleeding  continue,  or  if  it  commence  before  the  placenta  is  ex- 
pelled, the  hand  should  be  carefully  and  gently  passed  into  the  uterus, 
and  its  cavity  cleared  of  its  contents.  The  mere  presence  of  the  hand 
within  the  uterus  is  a  powerful  inciter  of  uterine  action.  When  the 
placenta  is  retained  it  is  the  more  essential,  as  the  hemorrhage  cannot 
possibly  be  checked  as  long  as  the  uterus  is  distended  by  it.  During 
the  operation  the  uterus  should  be  supported  by  the  left  hand  externally, 
and,  by  using  the  two  hands  in  concert,  the  chances  of  injuring  the 
textures  are  greatly  lessened. 

Treatment. of  Hour-glass  Contraction. — If  the  so-called  "hour- 
glass contraction  "  be  present,  or  if  the  placenta  be  morbidly  adherent, 
the  operation  will  be  more  difficult,  and  will  require  much  judgment 
and  care.  The  spasmodic  contraction  of  the  inner  os  in  the  former 
case  may  generally  be  overcome  by  gentle  and  continuous  pressure  of 
the  fingers  passed  within  the  contraction,  while  the  uterus  is  supported 
from  without.  By  this  means,  too,  further  hemorrhage  can  in  most 
cases  be  controlled  until  the  spasm  is  sufficiently  relaxed  to  admit  of 
the  passage  of  the  hand. 

Signs  of  Adherent  Placenta. — There  are  no  very  reliable  signs  to 
indicate  morbid  adhesion  of  the  placenta,  previous  to  the  introduction 
of  the  hand.  The  following  are  the  symptoms  as  laid  down  by  Barnes, 
any  of  which  might,  however,  accompany  non-detachment  of  the 
placenta  unaccompanied  by  adhesion:  "You  may  suspect  morbid 
adhesion  if  there  have  been  unusual  difficulty  in  removing  the  placenta 
in  previous  labors ;  if  during  the  third  stage  the  uterus  contracts  at 
intervals  firmly,  each  contraction  being  accompanied  by  blood,  and 
yet,  on  following  up  the  cord,  you  feel  the  placenta  in  utero ;  if,  on 
pulling  on  the  cord,  two  fingers  being  pressed  into  the  placenta  at  the 
root,  you  feel  the  placenta  and  uterus  descend  in  one  mass,  a  sense  of 
dragging  pain  being  elicited ;  if  during  a  pain  the  uterine  tumor  does 
not  present  a  globular  form,  but  is  more  prominent  than  usual  at  the 
place  of  placental  attachment." l 

Treatment  of  Adherent  Placenta. — The  artificial  removal  of  an 
adherent  placenta  is  always  a  delicate  and  anxious  operation,  which, 
however  carefully  performed,  must  of  necessity  expose  the  patient  to 
the  risk  of  injury  to  the  uterine  structures,  and  of  leaving  behind  por- 

i  Obstetric  Operations,  p.  440, 


442  LABOR. 

tions  of  placental  tissue,  which  may  give  rise  to  secondary  hemorrhage 
or  sapraemia.  The  cord  will  guide  the  hand  to  the  site  of  attachment, 
and  the  fingers  must  be  very  gently  insinuated  between  the  lower  edge 
of  the  placenta  and  the  uterine  wall ;  or,  if  a  portion  be  already 
detached,  we  may  commence  to  peel  off  the  remainder  at  that  spot. 
Supporting  the  uterus  externally,  we  carefully  pick  off  as  much  as 
possible,  proceeding  with  the  greatest  caution,  as  it  is  by  no  means  easy 
to  distinguish  between  the  placenta  and  the  uterus.  At  the  best,  it  is 
far  from  easy  to  remove  all,  and  it  is  wiser  to  separate  only  what  we 
readily  can  than  to  make  too  protracted  efforts  at  complete  detachment. 
When  it  is  found  to  be  impossible  to  detach  and  remove  the  whole  or 
a  great  part  of  the  placenta,  we  cannot  but  look  upon  the  further 
progress  of  the  case  with  considerable  anxiety.  The  retained  portions 
may  be,  ere  long,  spontaneously  detached  and  expelled,  or  they  may 
decompose  and  give  rise  to  fetid  discharge  and  septic  infection.  Such 
cases  must  be  treated  by  antiseptic  intra-uterine  injections,  so  as  to 
lessen  the  risk  of  absorption  as  much  as  possible ;  but  until  the  retained 
masses  have  been  expelled,  and  the  discharge  has  ceased,  the  patient 
must  be  considered  to  be  in  considerable  danger.  In  a  few  rare  cases, 
there  is  reason  to  believe  that  considerable  masses  of  retained  placental 
tissue  have  been  entirely  absorbed.  It  is  difficult  to  understand  so 
strange  a  phenomenon,  but  several  well-authenticated .  cases  are  re- 
corded in  which  there  seems  no  reason  to  doubt  that  the  retained 
placenta  was  removed  in  this  way.1 

Various  means  are  used  for  exciting  uterine  contraction  by  reflex 
stimulation.  Amongst  the  most  important  of  these  is  cold.  In 
patients  who  are  not  too  exhausted  to  respond  to  the  stimulus  applied, 
it  is  of  extreme  value.  But,  to  be  of  use,  it  should  be  used  intermit- 
tently, and  not  continuously.  Pouring  a  stream  of  cold  water  from  a 
height  on  the  abdomen  is  a  not  uncommon,  but  bad  practice,  as  it 
deluges  the  patient  and  bedding  in  water,  which  may  afterward  act 
injuriously.  Flapping  the  lower  part  of  the  abdomen  with  a  wet 
towel  is  less  objectionable.  Ice  can  generally  be  obtained,  and  a  piece 
should  be  introduced  into  the  uterus.  This  is  a  very  powerful  haemo- 
static, and  often  excites  strong  action  when  other  means  fail.  I  con- 
stantly employ  it,  and  have  never  seen  any  bad  results  follow.  A 
large  piece  of  ice  may  also  be  held  over  the  fundus,  and  removed, 
and  reapplied  from  time  to  time.  Iced  water  may  be  injected  into 
the  rectum.  A  very  powerful  remedy  is  washing  out  the  uterine 
cavity  with  a  stream  of  cold  water,  by  means  of  the  vaginal  pipe  of  a 
Higginson's  syringe  carried  up  to  the  fundus.  Another  means  of 
applying  cold,  said  to  be  very  effectual,  is  the  application  of  the  ether 
spray,  such  as  is  used  for  producing  local  anaesthesia,  over  the  lower 
part  of  the  abdomen.2  All  these  remedies,  however,  depend  for  their 
good  results  on  the  fact  of  the  patient  being  in  a  condition  to  respond 
to  stimulus  ;  and  their  prolonged  use,  if  they  fail  to  excite  contraction 
rapidly,  will  certainly  prove  injurious.  Rigby  used  to  look  upon  the 

1  See  an  interesting  paper  by  Dr.  Thrush  on  "Retention  of  the  Placenta  in  Labor  at  Term," 
Amer.  Journ.  of  Obstet.,  1877.  vol.  x.  pp.  389.  506. 

2  Griffiths-  Practitioner,  1877,  vol.  xviii.  p.  176 


HEMORRHAGE    AFTER    DELIVERY.  443 

application  of  the  child  to  the  breast  as  one  of  the  most  certain  inciters 
of  uterine  action.  It  may  be  of  service  after  the  hemorrhage  has  been 
checked,  in  keeping  up  tonic  contraction,  and  should  therefore  not  be 
omitted ;  but  we  certainly  cannot  waste  time  in  inducing  the  child  to 
suck  in  the  face  of  the  actual  emergency. 

Intra-uterine  injection  of  hot  water,  at  a  temperature  of  from  100° 
to  120°,  has  been  highly  recommended  as  a  powerful  means  of  arrest- 
ing post-partum  hemorrhage,  often  proving  eifectual  when  all  other 
treatment  has  failed. [L]  The  number  of  published  cases  in  which  it 
has  proved  of  great  value  is  now  considerable.  The  late  master  of 
the  Rotunda,  Dr.  Lombe  Atthill,  has  recorded  sixteen  cases2  in  which  it 
checked  hemorrhage  at  once,  in  many  of  which  ergot,  ice,  and  other 
means  had  failed.  He  speaks  of  it  as  especially  useful  in  those  trouble- 
some cases  in  which  the  uterus  alternately  relaxes  and  hardens,  and 
resists  all  our  efforts  to  produce  permanent  contraction.  Its  superiority 
to  cold  water  has  been  well  shown  by  Milne  Murray3  by  means  of  ex- 
periments on  pregnant  and  non-pregnant  rabbits,  which  proved  that 
while  cold  applications  produce  a  temporary  contraction,  when  applied 
for  any  length  of  time  they  rapidly  exhaust  the  excitability  of  the  uterine 
muscle,  while  the  reverse  effect  is  produced  when  hot  water  is  used. 
My  own  experience  of  this  treatment  is  very  favorable.  I  have  now 
used  it  in  many  cases,  in  some  of  which  the  tendency  to  hemorrhage 
was  very  great,  and  in  every  instance  it  has  at  once  produced  strong 
uterine  action  and  instantly  checked  the  flow.  It  is,  moreover,  much 
more  agreeable  to  the  patient  than  cold  applications.  It  is  advisable 
to  add  a  few  drops  of  creolin  to  the  hot  water,  which  is  in  itself  a 
good  antiseptic,  and  is  said  to  be  also  a  powerful  styptic.  I  think  it 
cannot  be  doubted  that  we  have  in  these  warm  irrigations  a  valuable 
addition  to  our  methods  of  treating  uterine  hemorrhage. 

The  late  Dr.  Earle  pointed  out*  that  a  distended  bladder  often  pre- 
vents contraction,  and  to  avoid  the  possibility  of  this  the  catheter 
should  be  passed. 

Since  1887  plugging  the  uterine  cavity  with  iodoform  gauze,  or, 
when  this  is  not  at  hand,  with  pledgets  of  cotton-wool  soaked  in  car- 
bolic solution,  has  been  thoroughly  advocated  in  Germany,  chiefly  by 
Diihrssen,5  but  since  the  publication  of  his  paper  a  large  number  of 
successful  cases  have  been  published6  in  which  this  treatment  has 
been  adopted,  so  that  it  must  be  admitted  as  a  useful  resource  in  cer- 
tain intractable  cases.  It  seems  to  act  m  tAvo  ways  :  first,  by  exciting 
energetic  and  continuous  uterine  contractions;  and  next,  by  direct 
pressure  on  the  bleeding  part.  In  applying  the  plugs,  the  patient 
should  be  placed  on  her  back,  the  cervix  drawn  down  with  a  volsella, 
and  long  strips  of  gauze  passed  up  to  the  fundus  with  ovum  forceps, 
until  the  uterine  cavity  is  completely  packed.  The  vagina  should  be 
subsequently  plugged  with  pledgets  of  cotton-wool  soaked  in  glycerin 
or  carbolized  water  and  dusted  with  iodoform.  The  plugs  may  be 

The  proper  temperature  is  115°.    Water  at  a  temperature  of  100°  has  a  tendency  to  favor  tne 

rv  9, 1878.  *  Edin.  Med.  Journ.,  1885-87,  pp.  131  215. 

*  Earle  :  Flooding  after  Delivery,  p.  163.  6  Volkmannische  Sammlung,  No.  347. 


•  See  Yea 


:  Flooding  after  Delivery,  p.  163. 
ear-book  of  Treatment,  1891. 


444  LABOR. 

allowed  to  remain  in  the  uterus  from  eight  to  twelve  hours,  by  which 
time  all  risk  of  recurrence  of  the  hemorrhage  will  be  at  ail  end.  I 
have  no  personal  experience  of  this  treatment,  but  the  evidence  in  its 
favor  is  strong.  It  is  clearly  one  which  can  only  be  resorted  to  in  very 
intense  cases  of  hemorrhage  when  all  other  means  have  failed.  It  will 
obviously  be  essential  to  carefully  watch  the  uterus,  to  make  sure  that 
blood  is  not  escaping  into  and  distending  its  cavity  above  the  plug. 
If  the  uterine  cavity  should  be  only  partially  or  ineffectually  filled, 
concealed  internal  hemorrhage  might  very  readily  be  going  on  without 
the  practitioner's  knowledge. 

Compression  of  the  abdominal  aorta  is  highly  thought  of  by  many 
Continental  authorities,  but  it  is  little  known  or  practised  in  this 
country.  It  has  been  objected  to  by  some  on  the  theoretical  ground 
that  the  hemorrhage  is  chiefly  venous,  not  arterial,  and  that  it  would 
only  favor  the  reflux  of  venous  blood  into  the  vena  cava.  Cazeaux 
points  out  that,  on  account  of  the  close  anatomical  relations  between 
the  aorta  and  the  vena  cava,  it  is  hardly  possible  to  compress  one 
vessel  without  the  other.  The  backward  flow  of  blood,  therefore, 
through  the  vena  cava  may  also  be  thus  arrested.  There  is  strong 
evidence  in  favor  of  the  occasional  utility  of  compression.  Its  chief 
recommendation  is  that  it  can  be  practised  immediately,  and  by  an 
assistant,  who  can  be  shown  how  to  apply  the  pressure.  It  is  most 
likely  to  prove  useful  in  sudden  and  severe  hemorrhage,  and,  if  it 
only  control  the  loss  for  a  few  moments,  it  gives  us  time  to  apply 
other  methods  of  treatment.  As  a  temporary  expedient,  therefore,  it 
should  be  borne  in  mind,  and  adopted  when  necessary.  It  has  the 
great  advantage  of  supplementing,  without  superseding,  other  and 
more  radical  plans  of  treatment.  The  pressure  is  very  easily  applied, 
on  account  of  the  lax  state  of  the  abdominal  walls.  The  artery  can 
readily  be  felt  pulsating  above  the  fundus  uteri,  and  can  be  com- 
pressed against  the  vertebrae  by  three  or  four  fingers  applied  length- 
wise. Baudelocque,  who  was  a  strong  advocate  of  this  procedure, 
stated  that  he  had,  on  several  occasions,  controlled  an  otherwise 
intractable  hemorrhage  in  this  way,  and  that  he,  on  one  occasion,  kept 
up  compression  for  four  consecutive  hours.  Cazeaux  believes  that 
compression  of  the  aorta  may  have  a  further  advantageous  effect  in 
retaining  the  mass  of  the  blood  in  the  upper  part  of  the  body,  and 
thus  lessening  the  tendency  to  syncope  and  collapse.  If  an  aortic 
tourniquet,  such  as  is  used  for  compressing  the  vessel  in  cases  of 
aneurism,  could  be  obtained,  it  might  be  used  with  advantage  in  such 
cases. 

If  a  battery  is  at  hand  the  faradic  current  may  be  used,  and  it  is  said 
to  be  a  very  powerful  agent  in  inducing  uterine  contraction,  one  pole 
being  introduced  into  the  uterus,  the  other  applied  over  it  through  the 
abdominal  parietes. 

When  the  hemorrhage  has  been  excessive,  and  there  is  profound 
exhaustion,  firm  bandaging  of  the  extremities,  by  preference  with 
Esmarch's  elastic  bandages  if  they  can  be  obtained,  may  be  advan- 
tageously adopted,  with  the  view  of  retaining  the  blood'  as  much  as 
possible  in  the  ,runk,  and  thus  lessening  the  tendency  to  syncope.  As 


HEMORRHAGE    AFTER    DELIVERY.  445 

a  temporary  expedient  in  the  worst  class  of  cases  it  may  occasionally 
prove  of  service. 

[Lives  of  patients  in  extremis  have  been  saved  by  the  expedient  of 
raising  the  body  of  the  woman  and  lowering  her  head,  so  as  to  turn 
the  current  of  blood  toward  the  brain.  This  may  have  to  be  repeated 
several  times  in  the  treatment  of  a  case  where  attacks  of  syncope  indi- 
cate it.  A  bladder  containing  ice  may  be  held  under  the  hand  of  the 
operator  over  the  abdomen  and  above  the  fundus  uteri,  and  compres- 
sion made  upon  the  uterus  and  aorta  at  the  same  time.  In  one  case  I 
was  forced,  by  the  long-continued  inertia  of  the  uterus  and  the  ten- 
dency to  a  return  of  hemorrhage,  to  keep  up  this  form  of  compression 
for  six  and  a  half  hours.  The  hand  of  the  operator  should  be  protected 
by  a  compress  of  flannel,  or  he  may  have  an  attack  of  local  neuralgia, 
or  possibly  rheumatism,  in  his  arm. — ED.] 

Supposing  these  means  fail,  and  the  uterus  obstinately  refuses  to 
contract  in  spite  of  all  our  efforts — and,  do  what  we  may,  cases  of  this 
kind  will  occur — the  only  other  agent  at  our  command  is  the  applica- 
tion of  a  powerful  styptic  to  the  bleeding  surface  to  produce  throm- 
bosis in  the  vessels.  "  The  latter,"  says  Dr.  Ferguson,1  alluding  to 
this  means  of  arresting  hemorrhage,  "appears  to  be  the  sole  means  of 
safety  in  those  cases  of  intense  flooding  in  which  the  uterus  flaps  about 
the  hand  like  a  wet  towel.  Incapable  of  contraction  for  hours,  yet 
ceasing  to  ooze  out  a  drop  of  blood,  there  is  nothing  apparently  be- 
tween life  and  death  but  a  few  soft  coagula  plugging  up  the  sinuses." 
These  form  but  a  frail  barrier  indeed,  but  the  experience  of  all  who 
have  used  the  injection  of  a  solution  of  perchloride  of  iron  in  such 
cases  proves  that  they  are  thoroughly  effectual,  and  their  introduction 
into  practice  is  one  of  the  greatest  improvements  in  modern  mid- 
wifery. Although  this  method  of  treating  these  obstinate  cases  is  not 
new,  since  it  was  practised  long  ago  in  Germany,  its  adoption  in  this 
country  is  unquestionably  due  to  the  energetic  recommendation  of  Dr. 
Barnes.  The  dangers  of  the  practice  have  been  strongly  insisted  on, 
and  with  a  degree  of  acrimony  that  is  to  be  regretted,  but  I  know  of 
only  one  published  case  in  which  its  use  has  been  followed  by  any 
evil  effects.  Its  extraordinary  power,  however,  of  instantly  checking 
the  most  formidable  hemorrhage  has  been  demonstrated  by  the  unani- 
mous testimony  of  all  who  have  tried  it.  As  it  is  not  proposed  by 
anyone  that  this  means  of  treatment  should  be  employed  until  all 
ordinary  methods  of  evoking  contraction  have  failed,  and  as,  in  cases 
of  this  kind,  the  lives  of  the  patients  are  of  necessity  imperilled,  we 
should  be  fully  justified  in  adopting  it,  even  if  its  possibly  injurious 
effects  had  been  much  more  certainly  proved.  It  is  surely  at  any  time 
justifiable  to  avoid  a  great  and  pressing  peril  by  running  a  possible 
chance  of  a  less  one.  Whenever,  therefore,  we  have  tried  the  plans 
above  indicated  in  vain,  no  time  should  be  lost  in  resorting  to  this 
expedient.  No  practitioner  should  attend  a  case  of  midwifery  without 
having  the  necessary  styptic  with  him.  The  best  and  most  easily 
obtainable  form  of  using  the  remedy  is  the  "liquor  ferri  perchloridi 

1  Preface  to  Gooch  "  On  Diseases  of  Women,"  p.  xlii.    New  Sydenham  Society,  1859. 


446  LABOR. 

fortior"  of  the  London  Pharmacopoeia,  which  should  be  diluted  for 
use  with  six  times  its  bulk  of  water.  This  is  certainly  better  than  a 
weaker  solution.  The  vaginal  pipe  of  a  Higginson's  syringe,  through 
which  the  solution  has  once  or  twice  been  pumped  to  exclude  the  air, 
is  guided  by  the  hand  to  the  fundus  uteri,  and  the  fluid  injected  gently 
over  the  uterine  surface.  The  loose  and  flabby  mucous  membrane  is 
instantaneously  felt  to  pucker  up,  all  the  blood  with  which  the  fluid 
comes  in  contact  is  coagulated,  and  the  hemorrhage  is  immediately 
arrested.  I  think  it  is  of  importance  to  make  sure  that  the  uterus  and 
vagina  are  emptied  of  clots  before  injection.  In  the  only  cases  in 
which  I  have  seen  any  bad  symptoms  follow,  this  precaution  had  been 
neglected.  The  iron  hardened  all  the  coagula,  which  remained  in  utero, 
and  saprsemia  supervened ;  which,  however,  disappeared  after  the  clots 
had  been  broken  up  and  wrashed  away  by  intra-uterine  antiseptic  in- 
jections. After  we  have  resorted  to  this  treatment,  all  further  pressure 
on  the  uterus  should  be  stopped.  We  must  remember  that  we  have 
now  abandoned  contraction  as  a  haemostatic,  and  are  trusting  to  throm- 
bosis, and  that  pressure  might  detach  and  lessen  the  coagula  which  are 
preventing  the  escape  of  blood. 

Other  local  astringents  may  be  eventually  found  to  be  of  use. 
Tincture  of  matico  possibly  might  be  serviceable,  although  I  am  not 
aware  that  it  has  been  tried.  The  styptic  properties  of  creolin  have 
already  been  mentioned.  Dupierris  has  advocated  tincture  of  iodine, 
and  has  recorded  twenty-four  cases  in  which  he  employed  it,  in  all 
without  accident,  and  with  a  successful  issue.  Penrose1  strongly 
recommends  common  vinegar,  which  has  the  advantage  of  being 
always  readily  obtainable.  He  speaks  highly  of  its  haemostatic  effect. 
He  soaks  a  clean  handkerchief  in  it,  and  introduces  it  by  the  hand 
into  tlje  uterine  cavity,  and  squeezes  it  over  the  endometrium.  He 
says  :  "  The  effect  of  the  vinegar  flowing  over  the  sides  of  the  cavity 
of  the  uterus  and  vagina  is  magical.  The  relaxed  and  flabby  uterine 
muscle  instantly  responds.  The  organ  assumes  what  is  called  its 
gizzard-like  feel,  shrinking  down  upon  and  compressing  the  operating 
hand,  and  in  the  vast  majority  of  cases  the  hemorrhage  ceases  in- 
stantly."2 This  is  certainly  worth  trying  before  the  iron  solution, 
which  is  not,  as  we  have  seen,  devoid  of  certain  risks. 

Hemorrhage  from  Laceration  of  Maternal  Structures. — A  word 
may  here  be  said  as  to  the  occasional  dependence  of  hemorrhage  after 
delivery  on  laceration  of  the  cervix  or  other  injury  to  the  maternal 
soft  parts.  Duncan  has  narrated  a  case  in  which  the  bleeding  came 
from  a  ruptured  perineum.  If  hemorrhage  continues  after  the  uterus 
is  permanently  contracted,  a  careful  examination  should  be  made  to 
astertain  if  any  such  injury  exist.  Most  generally  the  source  of  bleed- 
ing is  the  cervix,  and  the  flow  can  be  readily  arrested  by  swabbing 
the  injured  textures  with  a  sponge  saturated  in  a  solution  of  the  per- 
chloride. 

1  Trans.  Amer.  Gyn.  Soc.,  vol.  iii.  p.  148. 

[2  This  remedy  was  used  as  a  uterine  injection  with  signal  effect  in  a  case  of  violent  post-partum 
P5S??!™"1??,  by*  French  surgeon  in  country  practice  in  the  days  of  Astruc,  who  wrote  of  it  in 
1765  (Maladies  des  Femmes,  vol.  iv.  p.  227).— ED.] 


HEMORRHAGE    AFTER    DELIVERY.  447 

Secondary  Treatment. — The  secondary  treatment  of  post-partum 
hemorrhage  is  of  importance.  When  reaction  commences,  a  train  of 
distressing  symptoms  often  show  themselves,  such  as  intense  and 
throbbing  headache,  great  intolerance  of  light  and  sound,  and  general 
nervous  prostration ;  and,  when  these  have  passed  away,  we  have  to 
deal  with  the  more  chronic  effects  of  profuse  loss  of  blood.  Nothing 
is  so  valuable  in  relieving  these  symptoms  as  opium.  It  is  the  best 
restorative  that  can  be  employed,  but  it  must  be  administered  in  larger 
doses  than  usual.  Thirty  to  forty  drops  of  Battley's  solution  should 
be  given  by  the  mouth  or  in  an  enema.  At  the  same  time  the  patient 
should  be  kept  perfectly  still  and  quiet,  in  a  darkened  room,  and  the 
visits  of  anxious  friends  strictly  forbidden.  Strong  beef-essence  or 
gravy  soup,  milk,  or  eggs  beaten  up  with  milk,  and  similar  easily 
absorbed  articles  of  diet,  should  be  given  frequently,  and  in  small 
quantities  at  a  time.  Stimulants  will  be  required  according  to  the 
state  of  the  patient,  such  as  warm  brandy-and-water,  port  wine,  etc. 
Rest  in  bed  should  be  insisted  on,  and  continued  much  beyond  the 
usual  time.  Eventually  the  remedies  which  act  by  promoting  the 
formation  of  blood,  such  as  the  various  preparations  of  iron,  will  be 
found  useful,  and  may  be  required  for  a  length  of  time. 

Under  the  head  of  Transfusion,  I  have  separately  treated  the  appli- 
cation of  that  last  resource  in  those  desperate  cases  in  which  the  loss 
of  blood  has  been  so  excessive  as  to  leave  no  other  hope. 

Secondary  Post-partum  Hemorrhage. — In  the  majority  of  cases, 
if  a  few  hours  have  elapsed  after  delivery  without  hemorrhage,  we 
may  consider  the  patient  safe  from  the  accident.  It  is  by  no  means 
very  rare,  however,  to  meet  with  even  profuse  losses  of  blood  coming 
on  in  the  course  of  convalescence,  at  a  time  varying  from  a  few  hours 
or  days  up  to  several  weeks  after  delivery.  These  cases  are  described  • 
as  examples  of  secondary  hemorrhage,  and  they  have  not  received  an 
at  all  adequate  amount  of  attention  from  obstetric  writers,  inasmuch 
as  they  often  give  rise  to  very  serious,  and  even  fatal  results,  and  are 
always  somewhat  obscure  in  their  etiology  and  difficult  to  treat.  We 
owe  almost  all  our  knowledge  of  this  condition  to  an  excellent  paper 
by  Dr.  McClintock,  of  Dublin,  who  has  collected  characteristic  exam- 
ples from  the  writings  of  various  authors,  and  accurately  described  the 
causes  which  are  most  apt  to  produce  it. 

We  must,  in  the  first  place,  distinguish  between  true  secondary  hem- 
orrhage and  profuse  lochial  discharge  continued  for  a  longer  time 
than  usual.  The  latter  is  not  a  very  uncommon  occurrence,  and  is 
generally  met  with  in  cases  in  which  involution  of  the  uterus  has 
been  checked — as  by  too  early  exertion,  general  debility,  and  the  like. 
The  amount  of  the  lochial  discharge  varies  in  different  women.  In 
some  patients  it  habitually  continues  during  the  whole  puerperal 
month,  and  even  longer,  but  not  to  an  extent  which  justifies  us  in 
including  it  under  the  head  of  hemorrhage.  In  such  cases  prolonged 
rest,  avoidance  of  the  erect  posture,  occasional  small  doses  of  ergot, 
and,  it  may  be,  after  the  lapse  of  some  weeks,  astringent  injections  of 
oak-bark  or  alum,  will  be  all  that  is  necessary  in  the  way  of  treat- 
ment. 


448  LABOR. 

True  secondary  hemorrhage  is  often  sudden  in  its  appearance  and 
serious  in  its  effects.  McClintock  mentions  six  fatal  cases,  and  Mr. 
Bassett,1  of  Birmingham,  has  recorded  thirteen  examples  which  came 
under  his  own  observation,  two  of  which  ended  fatally. 

The  causes  may  be  either  constitutional,  or  some  local  condition  of 
the  uterus  itself. 

Constitutional  Causes. — Among  the  former  are  such  as  produce  a 
disturbance  of  the  vascular  system  of  the  body  generally,  or  of  the 
uterine  vessels  in  particular.  The  state  of  the  uterine  sinuses,  and  the 
slight  barrier  which  the  thrombi  formed  in  them  offer  to  the  escape 
of  blood,  readily  explain  the  fact  of  any  sudden  vascular  congestion 
producing  hemorrhage.  Thus  mental  emotions,  the  sudden  assump- 
tion of  the  erect  posture,  any  undue  exertion,  the  incautious  use  of 
stimulants,  a  loaded  condition  of  the  bowels,  or  sexual  intercourse 
shortly  after  delivery,  may  act  in  this  way.  McClintock  records  the 
case  of  a  lady  in  whom  very  profuse  hemorrhage  occurred  on  the 
twelfth  day  after  labor,  when  sitting  up  for  the  first  time.  Feeling 
faint  after  suckling,  the  nurse  gave  her  some  brandy,  whereupon  a 
gush  of  blood  ensued,  " deluging  all  the  bedclothes  and  penetrating 
through  the  mattress  so  as  to  form  a  pool  on  the  floor."  Here  the 
erect  position,  the  exquisite  pain  caused  by  nursing,  and  the  stimulat- 
ing drink,  all  concurred  to  excite  the  hemorrhage.  In  another  instance 
the  flooding  Avas  traced  to  excitement  produced  by  the  sudden  return 
of  an  old  lover  on  the  eighth  day  after  labor.  Moreau  especially 
dwells  on  the  influence  of  local  congestion  produced  by  a  loaded  con- 
dition of  the  rectum.  Constitutional  affections  producing  general 
debility  and  an  impoverished  state  of*  the  blood,  probably  also  may 
have  the  same  effect.  Blot  specially  mentions  albuminuria  as  one  of 
these,  and  Saboia  states  that  in  Brazil  secondary  hemorrhage  is  a  com- 
mon symptom  of  miasmatic  poisoning,  and  can  only  be  cured  by 
change  of  air  and  the  free  use  of  quinine.2 

Local  Causes. — Local  conditions  seem,  however,  to  be  the  more 
frequent  factors  in  the  production  of  secondary  hemorrhage.  These 
may  be  generally  classed  under  the  following  heads : 

1.  Irregular  and  inefficient  contraction  of  the  uterus. 

2.  Clots  in  the  uterine  cavity. 

3.  Portions  of  retained  placenta  or  membranes. 

4.  Retroflexion  of  the  uterus. 

5.  Laceration  or  inflammatory  state  of  the  cervix. 

6.  Thrombosis  or  hsematocele  of  the  cervix  or  vulva 

7.  Inversion  of  the  uterus. 

8.  Fibroid  tumors  or  polypus  of  the  uterus. 

The  first  four  of  these  need  only  now  be  considered,  the  others  being 
described  elsewhere. 

^  Relaxation  of  the  uterus  and  distention  of  its  cavity  by  coagula  may 
give  rise  to  hemorrhage,  although  not  so  readily  as  immediately  after 
delivery,  for  coagula  of  considerable  size  are  often  retained  in  uiero  for 
many  days  after  labor.  The  uterus  will  be  found  larger  than  it  ought 

1  Brit.  Med.  Journ.,  1872,  vol.  li.  pp.  216,  491. 
s  Saboia    Traite  des  Accouchements,  p.  819 


HEMORRHAGE    AFTER    DELIVERY.  449 

to  be,  and  tender  on  pressure.  Usually  the  coagula  are  expelled  with 
severe  after-pains ;  but  this  may  not  take  place,  and  hemorrhage  may 
ensue  several  days  after  delivery.  Or  there  may  be  only  a  relaxed 
state  of  the  uterus  without  retained  coagula.  Bassett  relates  four  cases 
traced  to  these  causes,  and  several  illustrations  will  be  found  in 
McClintock's  paper.  Portions  of  retained  placenta  or  membranes  are 
more  frequent  causes.  The  retention  may  be  due  to  carelessness  on 
the  part  of  the  practitioner,  especially  if  he  have  removed  the  placenta 
by  traction,  and  failed  to  satisfy  himself  of  its  integrity.  It  may, 
however,  often  be  due  to  circumstances  entirely  beyond  his  control ; 
such  as  adherent  placenta,  which  it  is  impossible  to  remove  without 
leaving  portions  in  utero,  or  more  rarely  placenta  succenturia.  In  the 
latter  case  there  is  a  small  supplementary  portion  of  placental  tissue 
developed  entirely  separate  from  the  general  mass,  and  it  may  remain 
in  utero  without  the  practitioner  having  the  least  suspicion  of  its  exist- 
ence. Portions  of  the  membranes  are  very  apt  to  be  left  in  utero.  It 
is  to  prevent  this  that  they  should  be  twisted  into  a  rope,  and  extracted 
very  gently  after  expression  of  the  placenta.  Hemorrhage  from  these 
causes  generally  does  not  occur  until  at  least  a  week  after  delivery,  and 
it  may  not  do  so  until  a  much  longer  time  has  elapsed.  In  four  cases 
recorded  by  Mr.  Bassett,  it  commenced  on  the  tenth,  twelfth,  four- 
teenth, and  thirty-second  day.  It  may  come  on  suddenly,  and  con- 
tinue ;  or  it  may  stop,  and  recur  frequently  at  short  intervals.  In  my 
experience  retention  of  portions  of  the  placenta  is  very  common  after 
abortion,  when  adhesions  are  more  generally  met  with  than  at  term.  In 
addition  to  the  hemorrhage  there  is  often  a  fetid  discharge,  due  to  de- 
composition of  the  retained  portion,  and  possibly  more  or  less  marked 
septic  symptoms,  wrhich  may  aid  in  the  diagnosis.  The  placenta  or 
membranes  may  simply  be  lying  loose  as  foreign  bodies  in  the  uterine 
cavity  ;  or  they  may  be  organically  attached  to  the  uterine  walls,  when 
their  removal  will  not  be  so  easily  effected. 

Barnes  has  especially  pointed  out  the  influence  of  retroflexion  of  the 
uterus  in  producing  secondary  hemorrhage,1  which  seems  to  act  by 
impeding  the  circulation  at  the  point  of  flexion,  and  thus  arresting  the 
pro<v->  of  involution. 

Treatment. — In  every  case  in  which  secondary  hemorrhage  occurs 
to  any  extent,  careful  investigation  into  the  possible  causes  of  the 
attack,  and  an  accurate  vaginal  examination,  are  imperatively  required. 
If  it  be  due  to  general  and  constitutional  causes  only,  we  must  insist 
on  the  most  absolute  rest  on  a  hard  bed  in  a  cool  room,  and  on  the 
absence  of  all  causes  of  excitement.  The  liquid  extract  of  ergot  will 
be  very  generally  useful  in  3j  doses  repeated  every  six  hours.  Mc- 
Clintock  strongly  recommends  the  tincture  of  Indian  hemp,  which 
mav  be  advantageously  combined  with  the  ergot,  in  doses  of  ten  or 
fifteen  minims,  suspended  in  mucilage.  Astringent  vaginal  pessaries 
of  matico  or  perchloride  of  iron  may  be  used.  Special  attention  should 
be  paid  to  the  state  of  the  bowels,  and  if  the  rectum  be  loaded,  it 
should  be  emptied  by  enemata.  In  more  chronic  cases  a  mixture  of 

i  Obstetric  Operations,  p.  492. 
29 


450  LABOR. 

ergot,  sulphate  of  iron,  and  small  doses  of  sulphate  of  magnesia  will 
prove  very  serviceable.  This  is  more  likely  to  be  effectual  when  the 
bleeding  is  of  an  atonic  and  passive  character.  McClintock  speaks 
strongly  in  favor  of  the  application  of  a  blister  over  the  sacrum. 
When  the  hemorrhage  is  excessive,  more  effectual  local  treatment  will 
be  required.  Cazeaux  advises  plugging  of  the  vagina.  Although  this 
cannot  be  considered  so  dangerous  as  immediately  after  delivery,  inas- 
much as  the  uterus  is  not  so  likely  to  dilate  above  the  plug,  still  it  is 
certainly  not  entirely  without  risk  of  favoring  concealed  internal  hem- 
orrhage. If  it  be  used  at  all,  the  uterine  cavity  should  be  plugged 
with  iodoform  gauze  as  well  as  the  vagina,  and  a  firm  abdominal  pad 
should  be  applied,  so  as  to  .compress  the  uterus;  and  the  abdomen 
should  be  examined  from  time  to  time,  to  insure  against  the  possibility 
of  uterine  dilatation.  With  these  precautions  the  plug  may  prove  of 
real  value.  In  any  case  of  really  alarming  hemorrhage  I  should  be 
disposed  rather  to  trust  to  the  application  of  styptics  to  the  uterine 
cavity.  The  injection  of  fluid  in  bulk,  as  after  delivery,  could  not  be 
safely  practised,  on  account  of  the  closure  of  the  os  and  the  contraction 
of  the  uterus.  But  there  can  be  no  objection  to  swabbing  out  the 
uterine  cavity  with  a  small  piece  of  sponge  attached  to  a  handle,  and 
saturated  with  tincture  of  iodine  or  with  a  solution  of  the  perchloride 
of  iron.  There  are  few  cases  which  will  resist  this  treatment. 

If  we  have  reason  to  suspect  retained  placenta  or  membranes,  or  if 
the  hemorrhage  continue  or  recur  after  treatment,  a  careful  exploration 
of  the  interior  of  the  womb  will  be  essential.  On  vaginal  examination, 
we  may  possibly  feel  a  portion  of  the  placenta  protruding  through  the 
os,  which  can  then  be  removed  without  difficulty.  If  the  os  be  closed 
it  must  be  dilated  with  Hegar's  dilators,  and  the  uterus  can  then  be 
thoroughly  explored.  This  ought  to  be  done  under  chloroform,  as  it 
cannot  be  effectually  accomplished  without  introducing  the  whole  hand 
into  the  vagina,  which  necessarily  causes  much  pain.  If  the  placenta 
or  membranes  be  loose  in  the  uterine  cavity,  they  may  be  removed  at 
once;  or  if  they  be  organically  attached,  they  may  be  carefully  picked 
off.  The  uterus  should  at  the  same  time,  as  long  as  the  os  remains 
patulous,  be  thoroughly  washed  out  with  creolin  and  water,  or  with  a 
1  in  2000  solution  of  perchloride  of  mercury,  to  diminish  the  risk  of 
saprffimia. 

Retroflexion  can  readily  be  detected  by  vaginal  examination,  and 
the  treatment  consists  in  careful  reposition  with  the  hand,  and  the 
application  of  a  large-sized  Hodge's  pessary. 


RUPTURE    OF    THE    UTERUS.  451 


CHAPTER   XYI. 

EUPTURE  OF  THE  UTERUS,   ETC. 

Rupture  of  the  uterus  is  one  of  the  most  dangerous  accidents  of 
labor,  and  until  of  late  years  it  has  been  considered  almost  necessarily 
fatal  and  beyond  the  reach  of  treatment.  Fortunately  it  is  not  of  very 
frequent  occurrence,  although  the  published  statistics  vary  so  much 
that  it  is  by  no  means  easy  to  arrive  at  any  conclusion  on  this  point. 
The  explauation  is,  no  doubt,  that  many  of  the  tables  confound  partial 
and  comparatively  unimportant  lacerations  of  the  cervix  and  vagina 
with  rupture  of  the  body  and  fundus.  It  is  only  in  large  lying-in 
institutions,  where  the  results  of  cases  are  accurately  recorded,  that 
anything  like  reliable  statistics  can  be  gathered,  for  in  private  practice 
the  occurrence  of  so  lamentable  an  accident  is  likely  to  remain  unpub- 
lished. To  show  the  difference  between  the  figures  given  by  authori- 
ties, it  may  be  stated  that,  while  Burns  calculates  the  proportion  to  be 
1  in  940  labors,  Ingleby  fixes  it  as  1  in  1300  or  1400,  Churchill  as  1 
in  1331,  and  Lehmann  as  1  in  2433.  Dr.  Jolly,  of  Paris,  has  pub- 
lished an  excellent  thesis  containing  much  valuable  information.1  He 
finds  that  out  of  782,741  labors,  230  ruptures,  excluding  those  of  the 
vagina  or  cervix,  occurred — that  is,  1  in  3403. 

Lacerations  may  occur  in  any  part  of  the  uterus — the  fundus,  the 
body,  or  the  cervix.  Those  of  the  cervix  are  comparatively  of  small 
consequence,  and  occur,  to  a  slight  extent,  in  almost  all  first  labors. 
Only  those  which  involve  the  supra-vaginal  portion  are  of  really  serious 
import.  Ruptures  of  the  upper  part  of  the  uterus  are  much  less  fre- 
quent than  of  the  portion  near  the  cervix ;  partly,  no  doubt,  because 
the  fundus  is  beyond  the  reach  of  the  mechanical  causes  to  which  the 
accident  can  not  unfrequeutly  be  traced,  and  partly  because  the  lower 
third  of  the  organ  is  apt  to  be  compressed  between  the  presenting 
part  and  the  bony  pelvis.  The  site  of  placental  insertion  is  said  by 
Madame  La  Chapelle  to  be  rarely  involved  in  the  rupture,  but  it  does 
not  always  escape,  as  numerous  recorded  cases  prove.  The  most  fre- 
quent seat  of  rupture  is  near  the  junction  of  the  body  and  neck,  either 
anteriorly  or  posteriorly,  opposite  the  sacrum,  or  behind  the  symphysis 
pubis ;  but  it  may  occur  at  the  sides  of  the  lower  segment  of  the  uterus. 
In  some  cases  the  entire  cervix  has  been  torn  away,  and  separated  in 
the  form  of  a  ring. 

The  laceration  may  be  partial  or  complete,  the  latter  being  the  more 
common.  The  muscular  tissue  alone  may  be  torn,  the  peritoneal  coat 
remaining  .intact ;  or  the  converse  may  occur,  and  then  the  peritoneum 
is  often  fissured  in  various  directions,  the  muscular  coat  being  unim- 

1  Rupture  Uterine  pendant  le  Travail,  Paris,  1873. 


452  LABOR. 

plicated.  The  extent  of  the  injury  is  very  variable,  in  some  cases 
being  only  a  slight  tear,  in  others  forming  a  large  aperture,  sufficiently 
extensive  to  allow  the  foetus  to  pass  into  the  abdominal  cavity.  The 
direction  of  the  laceration  is  as  variable  as  the  size,  but  it  is  more  fre- 
quently vertical  than  transverse  or  oblique.  The  edges  of  the  tear  are 
irregular  and  jagged ;  probably  on  account  of  the  contraction  of  the 
muscular  fibres,  which  are  frequently  softened,  infiltrated  with  blood, 
and  even  gangrenous.  Large  quantities  of  extravasated  blood  will  be 
found  in  the  peritoneal  cavity ;  such  hemorrhage,  indeed,  being  one  of 
the  most  important  sources  of  danger. 

Causes. — The  causes  are  divided  into  predisposing  and  exciting ;  and 
the  progress  of  modern  research  tends  more  and  more  to  the  conclusion 
that  the  cause  which  leads  to  the  laceration  could  only  have  operated 
because  the  tissue  of  the  uterus  was  in  a  state  predisposed  to  rupture, 
and  that  it  would  have  had  no  such  effect  on  a  perfectly  healthy  organ. 
What  these  predisposing  changes  are,  and  how  they  operate,  is  yet  far 
from  being  known,  and  the  subject  offers  a  fruitful  field  for  pathological 
investigation. 

It  is  generally  believed  that  lacerations  are  more  common  in  mul- 
tipart than  in  primiparae.  Tyler  Smith  contended  that  ruptures  are 
relatively  as  common  in  first  as  in  subsequent  labors,  while  Bandl1 
found  that  only  64  cases  out  of  546  ruptures  were  in  primiparae. 
Statistics  are  not  sufficiently  accurate  or  extensive  to  justify  a  positive 
conclusion,  but  it  is  reasonable  to  suppose  that  the  pathological  changes 
presently  to  be  mentioned  as  predisposing  to  laceration  are  more  likely 
to  be  met  with  in  women  whose  uteri  have  frequently  undergone  the 
alteration  attendant  on  repeated  pregnancies.  Age  seems  to  have  con- 
siderable influence,  as  a  large  proportion  of  cases  have  occurred  in 
women  between  thirty  and  forty  years  of  age. 

Alterations  in  the  tissues  of  the  uterus  are  probably  of  very 
great  importance  in  predisposing  to  the  accident,  although  our  infor- 
mation on  this  point  is  far  from  accurate.  Among  these  are  morbid 
states  of  the  muscular  fibres,  the  result  of  blows  and  contusions  during 
pregnancy ;  premature  fatty  degeneration  of  the  muscular  tissues,  n 
anticipation,  as  it  were,  of  the  normal  involution  after  delivery  ;  fibroid 
tumors  or  malignant  infiltration  of  the  uterine  walls,  which  either 
produce  a  morbid  state  of  the  tissues,  or  act  as  an  impediment  to  the 
expulsion  of  the  fcetus.  The  importance  of  such  changes  has  been 
specially  dwelt  on  by  Murphy  in  England  and  by  Lehmann  in 
Germany,  and  it  is  impossible  not  to  concede  their  probable  influence 
in  favoring  laceration.  However,  as  yet  these  views  are  founded  more 
on  reasonable  hypothesis  than  on  accurately  observed  pathological  facts. 

Another  and  very  important  class  of  predisposing  causes  are  those 
which  lead  to  a  want  of  proper  proportion  between  the  pelvis  and  the 
foetus. 

Deformity  of  the  pelvis  has  been  very  frequently  met  with  in 
cases  in  which  the  uterus  has  ruptured.  Thus  out  of  19  cases  carefully 
recorded  by  Radford,2  the  pelvis  was  contracted  in  11,  or  more  than 

1  Ueber  Ruptur  dcr  Gebarmutter.    Wien,  181.1.  -'  Obst.  Trans.,  1867,  vol.  viii.  p.  150. 


RUPTURE    OF    THE    UTERUS. 


453 


one-half.  Radford  makes  the  curious  observation  that  ruptures  seem 
more  likely  to  occur  when  the  deformity  is  only  slight,  and  he  ex- 
plains this  by  supposing  that  in  slight  deformities  the  lower  segment 
of  the  uterus  engages  in  the  brim,  and  is,  therefore,  much  subjected  to 
compression ;  while  in  extreme  deformity  the  os  and  cervix  uteri 
remain  above  the  brim,  the  body  and  fundus  of  the  uteri  hanging 
down  between  the  thighs  of  the  mother.  This  explanation  is  reason- 
able; but  the  rarity  with  which  ruptured  uterus  is  associated  with 
extreme  pelvic  deformity  may  rather  depend  on  the  infrequency  of 
advanced  degrees  of  contraction. 

FIG.  154. 


Illustrating  the  dangerous  thinning  of  the  lower  segment  of  the  uterus  owing  to  non-descent 
of  the  head  in  a  case  of  intra-uterine  hydrocephalus     (After  BAXDL.) 

Bandl,  wrho  has  made  the  most  important  of  modern  contributions 
to  our  knowledge  of  the  subject,  points  out  that  rupture  nearly  always 
begins  in  the  lower  segment  of  the  uterus,  which  becomes  abnormally 
stretched  and  distended  when  from  any  cause  the  expulsion  of  the  foetus 
is  delayed.  The  upper  portion  of  the  uterus  becomes,  at  the  same 
time,  retracted  and  much  thickened  (see  Fig.  154).  As  the  pains  con- 
tinue, the  stretching  of  the  lower  segment,  called  by  Spiegelberg  the 
"  obstetrical  cervix,"  becomes  more  and  more  marked,  until  at  last  its 
fibres  separate  and  a  laceration  is  established.  The  line  of  demarcation 
between  the  thickened  body  and  the  distended  lower  segment,  known 
as  the  ring  of  Bandl,  can,  in  such  cases,  be  occasionally  made  out  by 
palpation  above  the  pubes. 


454  LABOR. 

Amongst  the  causes  of  disproportion  depending  on  the  foetus  are 
either  malpresentation,  in  which  the  pains  cannot  effect  expulsion,  or 
undue  size  of  the  presenting  part.  In  the  latter  way  may  be  explained 
the  observation  that  rupture  is  more  frequently  met  with  in  the  deliv- 
ery of  male  than  of  female  children,  on  account,  no  doubt,  of  the  larger 
size  of  the  head  in  the  former.  The  influence  of  intra-uterine  hydro- 
cephalus  was  first  prominently  pointed  out  by  Sir  James  Simpson,1 
who  states  that  out  of  seventy-four  cases  of  intra-uterine  hydrocephalus 
the  uterus  ruptured  in  sixteen.  In  all  such  cases  of  disproportion, 
whether  referable  to  the  pelvis  or  foetus,  rupture  is  produced  in  a  two- 
fold manner — either  by  the  excessive  and  fruitless  uterine  contractions, 
which  are  induced  by  the  efforts  of  the  organ  to  overcome  the  obstacle ; 
or  by  the  compression  of  the  uterine  tissue  between  the  presenting  part 
and  the  bony  pelvis,  leading  to  inflammation,  softening,  and  even 
gangrene. 

The  proximate  cause  of  rupture  may  be  classed  under  two  heads — 
mechanical  injury  and  excessive  uterine  contraction.  Under  the  former 
are  placed  those  uncommon  cases  in  which  the  uterus  lacerates  as  the 
result  of  some  injury  in  the  latter  months  of  pregnancy,  such  as  blows, 
falls,  and  the  like.  Not  so  rare,  unfortunately,  are  lacerations  pro- 
duced by  unskilled  attempts  at  delivery  on  the  part  of  the  medical 
attendant,  such  as  by  the  hand  during  turning,  or  by  the  blades  of  the 
forceps.  Many  such  cases  are  on  record,  in  which  the  accoucheur  has 
used  force  and  violence,  rather  than  skill,  in  his  attempts  to  overcome 
an  obstacle.  That  such  unhappy  results  of  ignorance  are  not  so  un- 
common as  they  ought  to  be  is  proved  by  the  figures  of  Jolly,  who  has 
collected  seventy-one  cases  of  rupture  during  podalic  version,  thirty- 
seven  caused  by  the  forceps,  ten  by  the  cephalotribe,  and  thirty  during 
other  operations  the  precise  nature  of  which  is  not  stated.2  The  modus 
operandi  of  protracted  and  ineffectual  uterine  contractions,  as  a  proxi- 
mate cause  of  rupture,  is  sufficiently  evident,  and  need  not  be  dwelt  on. 
It  is  necessary  to  allude,  however,  to  the  effect  of  ergot,  incautiously 
administered,  as  a  producing  cause.  There  is  abundant  evidence  that 
the  injudicious  exhibition  of  this  drug  has  often  been  followed  by 
laceration  of  the  unduly  stimulated  uterine  fibres.  Thus,  Trask,  talk- 
ing of  the  subject,  says  that  Meigs  had  seen  three  cases,  and  Bedford 
four,  distinctly  traceable  to  this  cause.  Jolly  found  that  ergot  had 
been  administered  largely  in  thirty-three  cases  in  which  rupture 
occurred. 

Premonitory  Symptoms. — Some  have  believed  that  the  impending 
occurrence  of  rupture  could  frequently  be  ascertained  by  peculiar  pre- 
monitory symptoms,  such  as  excessive  and  acute  crampy  pains  about 
the  lower  part  of  the  abdomen,  due  to  the  compression  of  part  of  the 
uterine  walls.  These  are  far  too  indefinite  to  be  relied  on,  and  it  is 
certain  that  the  rupture  generally  takes  place  without  any  symptoms 
that  would  have  afforded  reasonable  grounds  for  suspicion. 

General  Symptoms. — The  symptoms  are  often  so  distinct  and 
alarming  as  to  leave  no  doubt  as  to  the  nature  of  the  case.  Xot  infre- 

'  Selected  Obst.  Works,  p.  385.  2  Op.  cit.,  p.  38. 


KUPTURE    OF    THE    UTERUS.  455 

quently,  however,  especially  if  the  laceration  be  partial,  they  are  by 
no  means  so  well  marked,  and  the  practitioner  may  be  uncertain  as  to 
what  has  taken  place.  In  the  former  class  of  cases  a  sudden  excruci- 
ating pain  is  experienced  in  the  abdomen,  generally  during  the  uterine 
contractions,  accompanied  by  a  feeling,  on  the  part  of  the  patient,  of 
something  having  given  way.  In  some  cases  this  has  been  accom- 
panied by  an  audible  sound,  which  has  been  noticed  by  the  bystanders. 
At  the  same  time  there  is  generally  a  considerable  escape  of  blood  from 
the  vagina,  and  a  prominent  symptom  is  the  sudden  cessation  of  the 
previously  strong  pains.  Alarming  general  symptoms  soon  develop, 
partly  due  to  shock,  partly  to  loss  of  blood,  both  external  and  internal. 
The  face  exhibits  the  greatest  suffering,  the  skin  becomes  deadly  cold 
and  covered  with  a  clammy  sweat,  and  fainting,  collapse,  rapid  feeble 
pulse,  hurried  breathing,  vomiting,  and  all  the  usual  signs  of  extreme 
exhaustion  quickly  follow. 

Abdominal  palpation  and  vaginal  examination  both  afford  character- 
istic indications  in  well-marked  cases.  If  the  child,  as  often  happens, 
has  escaped  entirely,  or  in  great  part,  into  the  abdominal  cavity,  it 
may  be  readily  felt  through  the  abdominal  walls ;  while  in  the  former 
case,  the  partially  contracted  uterus  may  be  found  separate  from  it  in 
the  form  of  a  globular  tumor,  resembling  the  uterus  after  delivery. 
Per  vaginam  it  may  generally  be  ascertained  that  the  presenting  part 
has  suddenly  receded,  and  can  no  longer  be  made  out,  or  some  other 
part  of  the  foetus  may  be  found  in  its  place.  If  the  rupture  be  exten- 
sive, it  may  be  appreciable  on  vaginal  examination,  and,  sometimes, 
a  loop  of  intestine  may  be  found  protruding  through  the  tear.  Other 
occasional  signs  have  been  recorded,  such  as  an  emphysematous  state 
of  the  lower  part  of  the  abdomen,  resulting  from  the  entrance  of  air 
into  the  cellular  tissue ;  or  the  formation  of  a  sanguineous  tumor  in 
the  hypogastrium  or  vagina.  These  are  too  uncommon  and  too  vague 
to  be  of  much  diagnostic  value. 

Unfortunately,  the  symptoms  are  by  no  means  always  so  distinct, 
and  cases  occur  in  which  most  of  the  reliable  indications,  such  as  the 
sudden  cessation  of  the  pains,  the  external  hemorrhage,  and  the  retro- 
cession of  the  presenting  part,  may  be  absent.  In  some  cases,  indeed, 
the  symptoms  have  been  so  obscure  that  the  real  nature  of  the  case  has 
only  been  detected  after  death.  It  is  rarely,  however,  that  the  occur- 
rence of  shock  and  prostration  is  not  sufficiently  distinct  to  arouse 
suspicion,  even  in  the  absence  of  the  usual  marked  signs.  In  not  a 
few  cases  distinct  and  regular  contractions  have  gone  on  after  lacera- 
tion, and  the  child  has  even  been  born  in  the  usual  way.  Of  course, 
in  such  a  case  mistake  is  very  possible.  So  curious  a  circumstance  is 
difficult  of  explanation.  The  most  probable  way  of  accounting  for  it 
is,  that  the  laceration  has  not  implicated  the  fundus  of  the  uterus, 
Avhich  contracted  sufficiently  energetically  to  expel  the  foetus.  Hence 
it  will  be  seen  that  the  symptoms  are  occasionally  obscure,  and  the 
practitioner  must  be  careful  not  to  overlook  the  occurrence  of  so 
serious  an  accident  because  of  the  absence  of  the  usual  and  character- 
istic symptoms. 

Prognosis. — The  prognosis  is  necessarily  of  the  gravest  possible 


456  LABOR. 

character,  but  modern  views  as  to  treatment  perhaps  justify  us  in  say- 
ing that  it  is  not  so  absolutely  hopeless  as  has  been  generally  taught 
in  our  obstetric  works.  When  we  reflect  on  what  has  occurred — the 
profound  nervous  shock ;  the  profuse  hemorrhage,  both  external  and, 
especially,  into  the  peritoneal  cavity,  where  the  blood  coagulates  and 
forms  a  ^foreign  body;  the  passage  of  the  uterine  contents  into  the 
abdomen,  with  the  inevitable  result  of  inflammation  and  its  conse- 
quences, if  the  patient  survive  the  primary  shock — the  enormous 
fatality  need  cause  no  surprise.  Jolly  has  found  that  out  of  580  eases 
100  recovered — that  is,  in  the  proportion  of  1  out  of  6.  This  is  a  far 
more  favorable  result  than  we  are  generally  led  to  anticipate ;  and  as 
many  of  the  recoveries  happened  in  apparently  the  most  desperate  and 
unfavorable  cases,  we  should  learn  the  lesson  that  we  need  not  abandon 
all  hope,  and  should  at  least  endeavor  to  rescue  the  patient  from  the 
terrible  dangers  to  which  she  is  exposed. 

As  regards  the  child,  the  prognosis  is  almost  necessarily  fatal ;  and, 
indeed,  the  cessation  of  the  foetal  heart-sounds  has  been  pointed  out  by 
McClintock  as  a  sign  of  rupture  in  doubtful  cases.  The  shock,  the 
profuse  hemorrhage,  and  the  time  that  must  necessarily  elapse  before 
the  delivery  of  the  child,  are  of  themselves  quite  sufficient  to  explain 
the  fact  that  the  foetus  is  almost  always  dead. 

Treatment. — From  what  has  been  said  of  the  impossibility  of  fore- 
telling the  occurrence  of  rupture,  it  must  follow  that  no  reliable 
prophylactic  treatment  can  be  adopted  beyond  that  which  is  a  matter 
of  general  obstetric  principle,  viz.,  timely  interference  when  the  uterine 
contractions  seem  incapable  of  overcoming  an  obstacle  to  delivery, 
either  on  the  part  of  the  pelvis  or  foetus. 

After  rupture  the  main  indications  are  to  effect  the  removal  of  the 
child  and  the  placenta,  to  rally  the  patient  from  the  effects  of  the 
shock,  and,  if  she  survive  so  long,  to  combat  the  subsequent  inflamma- 
tion and  its  consequences.  By  far  the  most  important  point  to  decide 
is  the  best  means  to  be  adopted  for  the  removal  of  the  child ;  for  it  is 
admitted  by  all  that  the  hopeless  expectancy  that  was  recommended 
by  the  older  accoucheurs,  or,  in  other  words,  allowing  the  patient  to  die 
without  making  any  effort  to  save  her,  is  quite  inadmissible.  If  the 
foetus  be  entirely  within  the  uterine  cavity,  no  doubt  the  proper  course 
to  pursue  is  to  deliver  at  once  per  vias  naturales,  either  by  turning,  by 
forceps,  or  by  cephalotripsy.  If  any  part  other  than  the  head  present, 
turning  will  be  best,  great  care  being  taken  to  avoid  further  increase 
of  the  laceration.  If  the  head  be  in  the  cavity  or  at  the  brim  of  the 
pelvis,  and  within  easy  reach  of  the  forceps,  it  may  be  cautiously 
applied,  the  child  being  steadied  by  abdominal  pressure  so  as  to 
facilitate  its  application.  If  there  be,  as  is  often  the  case,  some  slight 
amount  of  pelvic  contraction,  it  may  be  preferable  to  perforate  and 
apply  the  cephalotribe,  so  as  to  avoid  any  forcible  attempts  at  extrac- 
tion, which  might  unduly  exhaust  the  already  prostrate  patient  and 
turn  the  scale  against  her.  This  will  be  the' more  allowable,  since  the 
child  is,  as  we  have  seen,  almost  always  dead,  and  we  might  readily 
ascertain  if  it  be  so  by  auscultation. 

After  delivery  extreme  care  must  be  taken  in  removing  the  placenta, 


RUPTUKE    OF    THE    UTERUS.  457 

and  for  this  it  will  be  necessary  to  introduce  the  hand.  The  placenta 
will  generally  be  in  the  uterus,  for  if  the  rent  be  not  large  enough  for 
the  child  to  pass  through,  it  may  be  inferred  that  the  placenta  will  not 
have  done  so  either.  If  it  has  escaped  from  the  uterus,  very  gentle 
traction  on  the  cord  may  bring  it  within  reach  of  the  hand,  and  so  the 
passage  of  the  hand  through  the  tear  to  search  for  it  will  be  avoided ; 
but,  in  all  cases  of  this  kind,  there  must  have  been  a  very  considerable 
escape  of  blood  into  the  uterine  cavity,  and  abdominal  section  will 
probably  give  the  patient  a  better  chance  of  recovery. 

There  can  be  but  little  doubt  that,  in  the  cases  indicated,  such  is  the 
proper  treatment,  and  that  which  affords  the  mother  the  best  chance. 
Unfortunately,  the  cases  in  which  the  child  remains  entirely  in  utero 
are  comparatively  uncommon,  and  generally  it  will  have  escaped  into 
the  abdomen,  along  with  much  extravasated  blood.  The  usual  plan 
of  treatment  recommended  under  such  circumstances  is  to  pass  the 
hand  through  the  fissure  (some  have  even  recommended  that  it  should 
be  enlarged  by  incision  if  necessary),  to  seize  the  feet  of  the  foetus,  to 
drag  it  back  through  the  torn  uterus,  and  then  to  reintroduce  the  hand 
to  search  for  and  remove  the  placenta.  Imagine  what  occurs  during 
the  process.  The  hand  gropes  blindly  among  the  abdominal  viscera, 
the  forcible  dragging  back  of  the  foetus  necessarily  tears  the  uterus 
more  and  more,  and,  above  all,  the  extravasated  blood  remains  as  a 
foreign  body  in  the  peritoneal  cavity,  and  necessarily  gives  rise  to  the 
most  serious  consequences.  It  is  surely  hardly  a  matter  of  surprise 
that  there  is  scarcely  a  single  case  on  record  of  recovery  after  this 
procedure. 

Of  late  years  a  strong  feeling  has  existed  that,  whenever  the  child 
has  entirely,  or  in  great  part  escaped  into  the  abdominal  cavity,  the 
operation  of  coeliotomy  affords  the  mother  a  far  better  chance  of 
recovery ;  .and  it  has  now  been  performed  in  many  cases  with  the  most 
encouraging  results.  It  is  easy  to  see  why  the  prospects  of  success 
are  greater.  The  uterus  being  already  torn,  and  the  peritoneum 
opened,  the  only  additional  danger  is  the  incision  of  the  abdominal 
parietes,  which  gives  us  the  opportunity  of  washing  out  the  peritoneal 
cavity  and  of  removing  all  the  extravasated  blood,  the  retention  of 
which  so  seriously  adds  to  the  dangers  of  the  case,  as  well  as  closing  the 
rents  in  the  uterus,  if  it  be  within  reach,  with  both  deep  and  superficial 
sutures,  as  in  the  improved  Caesarean  section.  Another  advantage  is 
that,  if  the  patient  be  excessively  prostrate,  the  operation  may  be 
delayed  until  she  has  somewhat  rallied  from  the  effects  of  the  shock, 
whereas  delivery  by  the  feet  is  generally  resorted  to  as  soon  as  the 
rupture  is  recognized,  and  when  the  patient  is  in  the  worst  possible 
condition  for  interference  of  any  kind. 

Jolly  has  carefully  tabulated  the  results  of  the  various  methods  of 
treatment,  and,  making  every  allowance  for  the  unavoidable  errors  of 
statistics,  it  seems  beyond  all  question  that  the  results  of  coeliotomy 
are  so  greatly  superior  to  those  of  other  plans  that  I  think  its  adoption 
may  be  fairly  laid  down  as  a  rule  whenever  the  foetus  is  no  longer 
wholly  within  the  uterine  cavity. 


458 


LABOR. 


COMPARATIVE  RESULTS  OF  VARIOUS  METHODS  OF  TREATMENT  AFTER 
RUPTURE  OF  UTERUS. 


Treatment. 

No.  of  cases. 

Deaths. 

Recoveries. 

Per  cent,  of 
recoveries. 

144 

142 

2 

1.45 

Extraction  per  viat  naturalet     

382 

310 

72 

19 

38 

12 

26 

68.4 

Of  course,  this  table  will  not  justify  the  conclusion  that  68  per  cent, 
of  the  cases  of  ruptured  uterus  in  which  coeliotomy  is  performed  will 
recover ;  but  it  may  fairly  be  taken  as  proving  that  the  chances  of 
recovery  are  at  least  three  or  four  times  as  great  as  when  the  more 
usual  practice  is  adopted.1 

Porro's  operation  has  been  suggested  instead  of  simple  coeliotomy. 
In  seven  cases  tabulated  by  Godson,  in  which  this  operation  was  per- 
formed after  rupture  of  the  uterus,  the  mothers  all  died;2  but  this 
does  not  prove  that  this  plan,  which  adds  little  to  the  dangers  of  the 
case,  should  not  be  adopted.  It  has,  at  least,  the  advantage  of  effect- 
ually preventing  the  possibility  of  the  recurrence  of  rupture  in  a  future 
pregnancy. 

[Supra-vaginal  hysterectomy,  unless  preceded  by  a  true  Caesarean 
section,  has  no  right  or  title  to  the  name  of  "  Porro,"  any  more  than 
the  same  operation  for  a  uterine  fibroma  has.  The  method  has  two 
very  serious  objections  to  its  performance:  1,  it  is  generally  fatal  in 
its  results ;  2,  we  have  no  right  to  unsex  a  well-formed  woman  because 
she  has  had  the  misfortune  to  rupture  her  uterus,  when  a  better  result 
may  be  attained  by  carefully  suturing  the  laceration. — ED.] 

Lacerations  of  the  cervix  are  of  very  common  occurrence.  Occa- 
sionally, after  delivery,  they  may  cause  hemorrhage,  when  the  uterus 
itself  is  firmly  contracted ;  or  secondary  hemorrhage  during  the  puer- 
peral month.  As  a  rule  they  are  not  recognized,  and  it  is  only  of  late 
years,  and  chiefly  owing  to  the  labors  of  Emmet,  that  their  important 
influence  in  producing  various  chronic  forms  of  uterine  disease  has 
been  realized.  In  the  large  majority  of  cases  the  lacerations  are  lateral, 
either  on  one  or  both  sides  of  the  cervix.  If  they  give  rise  to 
hemorrhage,  the  local  application  of  styptics  is  probably  the  best  re- 
source. Whether  it  is  advisable  to  treat  severe  forms  by  the  imme- 
diate application  of  silver  sutures,  as  recommended  by  Fallen,3  is  a 
subject  as  yet  too  little  understood  to  justify  the  expression  of  an 
opinion. 

1  American  Puerperal  Oceliotomies.-A.fter  a  search  of  several  years,  I  have  thus  far  collected  forty 
cases  in  the  United  States,  with  twenty-one  women  and  two  children  saved.    One  mother  and 
child  were   saved  by  an  immediate  operation  with  a  pocket-knife,  in  1869.    I  presume  that  a 
general  record  of  American  operations  published  and  unpublished  would  show  a  saving  of  about 
50  per  cent.,  which  is  much  lower  than  that  claimed  by  Trask  and  Jolly,  collected  from  published 
reports,  and  less  than  I  thought  myself  a  year  ago.    Take  Trask's  fore'ign  cases,  twenty,  and  our 
own  forty,  and  we  have  native  and  foreign,  sixty,  with  thirty-seven  recoveries  and  twenty-three 
deaths.    I  look  upon  our  own  statistics  as  much  more  reliable,  because  many  of  the  unpublished 
cases  were  searched  out  by  correspondence.— Harris's  note  to  last  American  edition. 

2  A  successful  case  has  recently  been  reported  by  Professor  Slavjansky,  of  St.  Petersburg. 
•  Transactions  of  the  Intern.  Med.  Congress,  vol.  iv 


RUPTURE    OF    THE    UTERUS.  459 

It  is,  perhaps,  needless  to  say  that  the  operation  must  be  performed 
with  the  same  minute  care  that  has  raised  ovariotomy  to  its  present 
pitch  of  perfection,  and  that  special  attention  must  be  paid  to  the  wash- 
ing out  of  the  peritoneum,  the  removal  of  foreign  matters,  and  to  the 
careful  suturing  of  the  uterine  wound,  whenever  that  is  practicable. 

Recapitulation. — To  recapitulate,  I  think  what  has  been  said  justi- 
fies the  following  rules  of  treatment  after  rupture : 

1.  If  the  head  or  presenting  part  be  above  the  brim,  and  the  foetus 
still  in  utwo — forceps,  turning,  or  cephalotripsy  according  to  circum- 
stances. 

2.  If  the  head  be  in  the  pelvic  cavity — forceps  or  cephalotripsy. 

3.  If  the  foetus  have  wholly,  or  in  great  part,  escaped   into  the 
abdominal  cavity— coeliotomy. 

As  to  the  subsequent  treatment,  little  need  be  said,  since  in  this 
we  must  be  guided  by  general  principles.  The  chief  indication  will 
be  to  remove  shock,  to  rally  the  patient  by  stimulants,  etc.,  and  to 
combat  secondary  results  by  opiates  and  other  appropriate  remedies. 

Drainage  has  been  recommended  in  cases  in  which  coeliotomy  has 
not  been  resorted  to,  and  the  results  are  said  to  have  been  good. 
Mann1  advises  that  a  large  piece  of  drainage-tube  should  be  bent  in 
the  middle,  at  which  point  a  free  opening  should  be  made.  This  bent 
portion  is  passed  for  about  half  an  inch  through  the  laceration,  the 
free  ends  are  fastened  together  beyond  the  vulva,  and  covered  with  an 
antiseptic  dressing.  After  forty-eight  hours  the  wound  should  be 
regularly  irrigated  with  2  per  cent,  solution  of  carbolic  acid. 

Lacerations  of  the  vagina  occasionally  take  place,  and  in  the 
great  majority  of  cases  they  are  produced  by  instruments,  either  from 
a  want  of  care  in  their  introduction,  or  from  undue  stretching  of  the 
vaginal  walls  during  extraction  with  the  forceps.  Slight  vaginal 
lacerations  are  probably  much  more  common  after  forceps  delivery 
than  is  generally  believed  to  be  the  case.  As  a  rule,  they  are  produc- 
tive of  no  permanent  injury,  although  it  must  not  be  forgotten  that 
every  breach  of  continuity  increases  the  risk  of  subsequent  septic 
absorption.  When  the  laceration  is  sufficiently  deep  to  tear  through 
the  recto- vaginal  septum  or  the  anterior  vaginal  wall,  the  passage  of 
the  urine  or  feces  is  apt  to  prevent  its  edges  uniting ;  then  that  most 
distressing  condition,  recto-vaginal  or  vesico-vaginal  fistula,  is  estab- 
lished. 

It  must  not  be  supposed  that  fistulse  are  often  the  result  of  injury 
during  operative  interference.  That  is  a  common  but  very  erroneous 
opinion  both  among  the  profession  and  the  public.  In  the  vast 
majority  of  cases  the  fistulous  opening  is  the  consequence  of  a  slough 
resulting  from  inflammation,  produced  by  long-continued  pressure  of 
the  vaginal  walls  between  the  child's  head  and  the  bony  pelvis,  in 
cases  in  which  the  second  stage  has  been  allowed  to  go  on  too  long. 
In  most  of  these  cases  instruments  were  doubtless  eventually  used, 
and  they  get  the  blame  of  the  accident ;  whereas  the  fault  lay,  not  'in 
their  being  employed,  but  rather  in  their  not  having  been  used  soon 

1  Centralblatt  f.  Gynak.,  1881,  Bd.  v.  S.  377. 


460  LABOR. 

enough  to  prevent  the  contusion  and  inflammation  which  ended  in 

sloughing. 

When  vesico-vaginal  fistulas  are  the  result  of  lacerations  during 
labor,  the  urine  must  escape  at  once ;  but  this  is  rarely  the  case.  In 
the  large  majority  of  cases  the  urine  does  not  pass  per  vaginam  until 
more  than  a  week  after  delivery,  showing  that  a  lapse  of  time  is  neces- 
sary for  inflammatory  action  to  lead  to  sloughing.  In  order  to  throw 
some  light  on  these  points,  on  which  very  erroneous  views  have  been 
held,  I  have  carefully  examined  the  histories,  from  various  sources,  of 
63  cases  of  vesico-vaginal  fistula. 

Statistical  Facts. — 1st.  In  20  no  instruments  were  employed.  Of 
these,  there  were  in  labor 

Under  24  hours    . 2 

From  24  to  48      " 8i 

"      40  to  70      " 2 

"      70to8f      " 7 

"     80  hours  and  upward 1 

20 

Therefore  out  of  these  20  cases  one-half  were  certainly  more  than 
forty-eight  hours  in  labor,  and  6  of  the  remaining  10  were  probably 
so  also.  In  only  one  of  them  is  the  urine  stated  to  have  escaped  per 
vcginam  immediately  after  delivery.  In  7  it  is  said  to  have  done  so 
within  a  week,  and  in  the  remainder  after  the  seventh  day. 

2d.  In  34  cases  instruments  were  used,  but  there  is  no  evidence  of 
their  having  produced  the  accident.  Of  these  there  were  in  labor 

Under  24  hours .  2 

From  24  to  48     " .        .        .8 

"     48  to  72     " 10 

"    72  hours  and  upward 14 

34 

The  urine  escaped  within  twenty-four  hours  in  2  cases  only,  within  a 
week  in  16,  and  after  the  seventh  day  in  15. 

So  that  here  again  we  have  the  history  of  unduly  protracted  'de- 
livery, 24  out  of  the  34  having  been  certainly  more  than  forty-eight 
hours  in  labor. 

3d.  In  9  cases  the  histories  show  that  the  production  of  the  fistula 
may  fairly  be  ascribed  to  the  unskilled  use  of  instruments.  Of  these 
there  were  in  labor 

Under  24  hours .       .      7 

From  24  to  48      " 1 

"   48  to  72      " 1 

9 

The  urine  escaped  at  once  in  7  cases,  and  in  the  remaining  2  after  the 
seventh  day. 

These  statistics  seem  to  me  to  prove,  in  the  clearest  manner,  that, 
in  the  large  majority  of  cases,  this  unhappy  accident  may  be  directly 
traced  to  the  bad  practice  of  allowing  labor  to  drag  on  many  hours  in 
the  second  stage  without  assistance,  and  not  to  premature  instrumental 
interference.  This  question  has  recently  been  elaborately  studied  by 

i  But  of  these  in  7  no  precise  time  is  stated.  Six  of  them  are  marked  very  tedious,  therefore  they 
probably  exceeded  the  limit. 


RUPTURE    OF    THE    UTERUS.  461 

Emmet,  who  gives  numerous  statistical  tables  which  fully  corroborate 
these  views.  His  conclusion,  the  result  of  much  practical  experience 
of  vesico-vaginal  fistulae,  is  worthy  of  being  quoted  :  "  I  do  not  hesi- 
tate," he  says,  "  to  make  the  statement  that  I  have  never  met  with  a 
case  of  vesico-vaginal  fistula  which,  without  doubt,  could  be  shown  to 
have  resulted  from  instrumental  delivery.  On  the  contrary,  the  entire 
weight  of  evidence  is  conclusive  in  showing  that  the  injury  is  a  conse- 
quence of  delay  in  delivery." 1 

Treatment. — As  to  the  treatment  of  vaginal  laceration,  little  can  be 
said.  In  the  slighter  cases  antiseptic  vaginal  injections  will  be  useful 
to  lessen  the  risk  of  septic  absorption ;  and  the  graver,  when  vesico- 
vaginal  or  recto-vaginal  fistulse  have  actually  formed,  are  not  within 
the  domain  of  the  obstetrician,  but  must  be  treated  surgically  at  some 
future  date. 

[The  Rational  Treatment  of  Rupture  of  the  Uterus. — The  three 
rules  given  on  page  459  are  those  found  in  obstetrical  works  of 
high  authority,  but  are  not  based  upon  the  teachings  of  abdominal 
surgery  as  shown  by  the  results  of  operations  recorded  within  a  few 
years.  Reasoning  from  analogy  and  the  fearful  mortality  of  cases 
delivered  per  vias  naturales  after  uterine  rupture,  we  are  forced  to  the 
conclusion  that  something  more  is  needed  than  the  delivery  of  the 
woman  and  the  removal  of  the  placenta  if  we  hope  to  reduce  the  pro- 
portion of  deaths,  which  is  very  great  except  after  cceliotomy — a  method 
of  delivery  capable  of  saving  nearly  50  per  cent.  There  is  no  objection 
to  delivering  the  foetus  by  the  natural  channel,  provided  it  can  be 
readily  done ;  but  we  have  very  little  reason  to  anticipate  a  favorable 
result  if  we  rest  our  efforts  here.  Children  entirely  escaped  into  the 
abdominal  cavity  have  been  drawn  back  through  the  rent  and  delivered 
by  the  vagina,  and  the  women  have  recovered,  In  one  well-authen- 
ticated case  the  woman  was  thus  saved  in  our  own  country  on  four 
occasions.  But  we  are  not  to  expect  such  results,  as  a  fatal  issue  is  far 
more  frequent  than  a  recovery  under  such  circumstances.  Our  object 
should  be  to  save  the  life  of  the  mother  and,  if  at  all  possible,  that  of 
the  foetus,  and  all  our  efforts  should  be  directed  to  this  end.  We  may 
console  ourselves  with  having  delivered  the  woman  prior  to  her  death, 
but  to  prevent  this  fatal  issue  should  be  our  chief  aim.  The  general 
impression  among  ovariotomists  is,  that  blood  is  not  an  innocent  fluid 
in  the  abdominal  cavity ;  and  the  remarkable  results  of  the  operations 
of  Dr.  Keith,  of  London,  formerly  of  Edinburgh,  are  attributed  to  the 
care  he  exercised  in  preventing  the  secondary  escape  of  blood  into  the 
abdominal  cavity.  The  late  Dr.  Ludwig  Winckel,  of  Mullheim,  Ger- 
many, who  performed  the  Caesareau  operation  fourteen  times  and 
coeliotomy  after  rupture  of  the  uterus  four  times,  was  of  the  impression 
that  the  liquor  amuii  was  innocuous  if  only  a  short  time  in  contact 
with  the  peritoneum  ;  and  the  same  may  be  said  of  blood,  ovarian  fluid, 
parovarian  fluid,  and,  to  some  degree,  also  of  urine.  Rupture  of  the 
bladder  is  now  cured  by  sewing  up  the  rent  and  carefully  cleansing  the 
abdominal  cavity  of  blood  and  urine.  But  these  fluids  are  all  capable 

1  The  Principles  and  Practice  of  Gynecology,  p.  669. 


462  LABOR. 

of  setting  up  peritonitis,  and  blood  by  its  decomposition  is  particularly 
apt  to  give  rise  to  septic  poisoning ;  then  why  let  it  remain  in  the 
abdominal  cavity  in  cases  of  ruptured  uterus  ?  If  it  is  important  to 
cleanse  this  cavity  from  blood  and  ovarian  fluid  in  ovariotomy,  and 
from  blood  and  amniotic  fluid  after  the  Csesarean  section,  then  why 
should  we  be  content  with  delivering  the  foetus  in  cases  of  rupture  of 
the  uterus,  when  we  know  that  the  peritoneal  cavity  still  contains  a 
compound  fluid  which  may  destroy  the  woman  if  not  removed  and  the 
parts  cleansed  ?  We  have  also  an  additional  risk  in  the  fact  that  the 
uterine  rupture  may  gape  and  allow  the  lochia  to  escape  into  the  peri- 
toneal cavity,  thus  providing  another  element  for  septic  poisoning.  I 
am,  then,  fully  persuaded  that  in  all  cases  of  rupture,  where  it  is  evi- 
dent that  blood  and  liquor  amnii  have  escaped  into  the  abdominal 
cavity,  we  ought  to  open  the  abdomen,  cleanse  out  the  cavity,  and  close 
up  the  rent  by  deep-seated  and  superficial  sutures  of  carbolized  pure 
silk.  In  cervico-vaginal  rupture  the  closure  of  the  rent  may  not  be  so 
important  in  the  sense  of  safety  to  the  woman,  as  there  is  generally  a 
natural  drainage  into  the  vagina ;  neither  is  creliotorny  itself  so  im- 
peratively demanded  as  in  cases  where  the  fundus  or  body  of  the  uterus 
is  rent.  But  it  becomes  important  to  close  the  torn  cervix  in  view  of 
future  trouble  from  ectropium  and  erosion.  As  in  the  Csesarean  oper- 
ation, promptness  of  action  is  all-important  if  we  hope  to  save  the 
patient.  I  know  that  these  views  upon  the  treatment  of  ruptured 
uterus  are  in  advance  of  those  held  by  British  obstetrical  writers,  but 
they  are  certainly  logical  deductions  from  the  experience  of  such 
operators  as  Dr.  Keith,  Mr.  Lawson  Tait,  and  others,  and  from  the 
well-known  results  of  promptly  performed  coeliotomies  in  rupture  acci- 
dents in  the  United  States.  The  removal  of  the  uterus  after  rupture 
has  as  yet  only  added  to  the  risk,  and  I  do  not  believe  we  are  justified 
in  resorting  to  it  where  there  is  no  pelvic  obstruction. — ED.] 


CHAPTER    XYII 

INVERSION  OF  THE   UTERUS. 

Inversion  of  the  uterus  shortly  after  the  birth  of  the  child  is  one 
of  the  most  formidable  accidents  of  parturition,  leading  to  symptoms 
of  the  greatest  urgency,  not  rarely  proving  fatal,  and  requiring  prompt 
and  skilful  treatment.  Hence  it  has  obtained  an  unusual  amount  of 
attention,  and  there  are  few  obstetric  subjects  which  have  been  more 
carefully  studied. 

Fortunately,  the  accident  is  of  great  rarity.  It  was  only  observed 
once  in  upward  of  190,800  deliveries  at  the'  Rotunda  Hospital  since 
its  foundation  in  1745  ;  and  many  practitioners  have  conducted  large 


INVERSION    OF    THE    UTERUS. 


463 


FIG.  155. 


midwifery  practices  for  a  lifetime  without  ever  having  witnessed  a  case. 
It  is  none  the  less  needful,  however,  that  we  should  be  thoroughly 
acquainted  with  its  natural  history,  and  with  the  best  means  of  dealing 
with  the  emergency  when  it  arises. 

Acute  and  Chronic  Forms. — Inversion  of  the  uterus  may  be  met 
with  in  the  acute  or  chronic  form ;  that  is  to  say,  it  may  come  under 
observation  either  immediately  or  shortly  after  its  occurrence,  or  not 
until  after  a  considerable  lapse  of  time,  when  the  involution  following 
pregnancy  has  been  completed.  The  latter  falls  more  properly  under 
the  province  of  the  gynecologist,  and  involves  the  consideration  of 
many  points  that  would  be  out  of  place  in  a  work  on  obstetrics.  Here., 
therefore,  the  acute  form  alone  is  considered. 

Description. — Inversion  consists  essentially  in  the  enlarged  and 
empty  uterus  being  turned  inside  out,  either  partially  or  entirely ;  and 
this  may  occur  in  various  degrees,  three  of  which  are  usually  described, 
and  are  practically  useful  to  bear  in  mind.  In  the  first  and  slightest 
degree  there  is  merely  a  cup-shaped  depression  of  the  fundus  (Fig. 
155);  in  the  second  the  depression  is 
greater,  so  that  the  inverted  portion  forms 
an  introsusception,  as  it  were,  and  pro- 
jects downward  through  the  os  in  the  form 
of  a  round  ball,  not  unlike  the  body  of  a 
polypus,  for  which,  indeed,  a  careless  ob- 
server might  mistake  it ;  and,  thirdly, 
there  is  the  complete  variety,  in  which 
the  whole  organ  is  turned  inside  out  and 
may  even  project  beyond  the  vulva. 

The  symptoms  are  generally  very 
characteristic,  although,  when  the  amount 
of  inversion  is  small,  they  may  entirely 
escape  observation .  They  are  chiefly  those 
of  profound  nervous  shock,  viz.,  fainting, 
small,  rapid,  and  feeble  pulse,  possibly 
convulsions  and  vomiting,  and  a  cold, 
clammy  skin.  Occasionally  severe  ab- 
dominal pain  and  bearing  down  are  felt. 
Hemorrhage  is  a  frequent  accompani- 
ment, sometimes  to  a  very  alarming  ex- 
tent, especially  if  the  placenta  be  partially 
or  entirely  detached.  The  loss  of  blood 
depends  to  a  great  extent  on  the  condition  of  the  uterine  parietes.  If 
there  be  much  contraction  on  the  part  that  is  not  inverted,  the  intro- 
suscepted  part  may  be  sufficiently  compressed  to  prevent  any  great 
loss.  If  the  entire  organ  be  in  a  state  of  relaxation  the  loss  may  be 
excessive. 

The  occurrence  of  such  symptoms  shortly  after  delivery  would  of 
necessity  lead  to  an  accurate  examination,  when  the  nature  of  the  case 
may  be  at  once  ascertained.  On  passing  the  finger  into  the  vagina  we 
either  find  the  entire  uterus  forming  a  globular  mass — to  which  the 
placenta  is  often  attached — or,  if  the  inversion  be  incomplete,  the 


Partial  inversion  of  the  fundus. 
(From  a  preparation  in  the  Museum 
of  Guy's  Hospital.) 


464  LABOR. 

vagina  is  occupied  by  a  firm,  round,  and  tender  swelling,  which  can 
be  traced  upward  through  the  os  uteri.  The  hand  placed  on  the 
abdomen  will  detect  the  absence  of  the  round  ball  of  the  contracted 
uterus;  the  bimanual  examination  may  even  enable  us  to  feel  the  cup- 
shaped  depression  at  the  site  of  inversion. 

Differential  Diagnosis. — When  such  signs  are  observed  immedi- 
ately after  delivery  mistake  is  hardly  possible.  Numerous  instances, 
however,  are  recorded  in  which  the  existence  of  inversion  was  not 
immediately  detected,  and  the  tumor  formed  by  it  only  observed  after 
the  lapse  of  several  days,  or  even  longer,  when  the  general  symptoms 
led  to  vaginal  examination.  It  is  probable  that,  in  such  cases,  a 
partial  inversion  had  taken  place  shortly  after  delivery,  which,  as  time 
elapsed,  became  gradually  converted  into  the  more  complete  variety. 
In  a  case  of  this  kind,  as  in  a  chronic  inversion,  some  care  is  necessary 
to  distinguish  the  inversion  from  a  uterine  polypus,  which  it  closely 
resembles.  The  cautious  insertion  of  the  sound  will  render  the  diag- 
nosis certain,  since  its  passage  is  soon  arrested  in  inversion  ;  while,  if 
the  tumor  be  polypoid,  it  readily  passes  in  as  far  as  the  fund  us. 

The  mechanism  by  which  inversion  is  produced  is  well  worthy 
of  study,  and  has  given  rise  to  much  difference  of  opinion. 

A  very  general  theory  is  that  it  is  caused,  in  many  cases,  by  mis- 
management of  the  third  stage  of  labor,  either  by  traction  on  the  cord, 
the  placenta  being  still  adherent,  or  by  improperly  applied  pressure  on 
the  fundus ;  the  result  of  both  these  errors  being  a  cup-shaped  depres- 
sion of  the  fundus,  which  is  subsequently  converted  into  a  more  com- 
plete variety  of  inversion.  That  such  causes  may  suffice  to  start  the 
inversion  cannot  be  doubted,  but  it  is  probable  that  their  frequency 
has  been  much  exaggerated.  Still,  there  are  numerous  recorded  cases 
in  which  the  commencement  of  the  inversion  can  be  traced  to  them. 
Improperly  applied  pressure  (as  when  the  whole  body  of  the  uterus  is 
not  grasped  in  the  hollow  of  the  hand,  but  when  a  monthly  nurse,  or 
other  uninstructed  person,  presses  on  the  lower  part  of  the  abdomen, 
so  as  simply  to  push  down  the  uterus  en  masse)  is  often  mentioned  in 
histories  of  the  accident.  Thus,  in  the  Edinburgh  Medical  Journal  for 
June,  1848,  a  case  is  related  in  which  the  patient  would  not  have  a 
medical  man,  but  was  attended  by  a  midwife,  who,  after  the  birth  of 
the  child,  pulled  on  the  cord,  while  the  patient  herself  clasped  her 
hands  and  pushed  down  her  abdomen,  at  the  same  time  straining 
forcibly,  when  the  uterus  became  inverted  and  the  patient  died  of 
hemorrhage  before  assistance  could  be  procured.  Here  both  of  the 
mechanical  causes  alluded  to  were  in  operation.  In  several  cases  it  is 
mentioned  that  the  accident  occurred  while  the  nurse  was  compressing 
the  abdomen.  That  the  accident  is  practically  impossible  when  firm 
and  equable  contraction  has  taken  place  cannot  be  questioned.  Hence 
it  is  of  paramount  importance  that  the  practitioner  should  himself 
carefully  attend  to  the  conduct  of  the  third  stage  of  labor. 

In  a  large  proportion  of  cases  no  mechanical  causes  can  be  traced, 
and  the  occurrence  of  spontaneous  inversion  must  be  admitted.  There 
are  various  theories  held  as  to  how  this  occurs.  Partial  and  irregular 
contraction  of  the  uterus  is  generally  admitted  to  be  an  important 


INVERSION    OF    THE    UTERUS. 


465 


factor  in  its  production ;  but  it  is  still  a  matter  of  dispute  whether  the 
inversion  is  produced  mainly  by  an  active  contraction  of  the  fimdus 
and  body  of  the  uterus,  the  lower  portion  and  cervix  being  in  a  state 
of  relaxation ;  or  whether  the  precise  reverse  of  this  exists,  the  fimdus 
being  relaxed  and  in  a  state  of  quasi-paralysis,  while  the  cervix  and 
lower  portion  of  the  uterus  are  irregularly  contracted.  The  former  is 
the  view  maintained  by  Radford  and  Tyler  Smith,  while  the  latter  is 
upheld  by  Matthews  Duncan. 

There  are  good  clinical  reasons  for  believing  that  Duncan's  view 
more  nearly  corresponds  with  the  true  facts  of  the  case ;  for,  if  the 
fimdus  and  body  of  the  uterus  be  really  in  a  state  of  active  contraction, 
while  the  cervix  is  relaxed,  we  have,  as  Duncan  points  out,  the  very 
condition  which  is  normal  and  desirable  after  delivery,  and  that  which 
we  do  our  best  to  produce.  If,  however,  the  opposite  condition  exists, 
and  the  fimdus  be  relaxed,  while  the  lower  portion  is  spasmodically 
contracted,  a  state  exists  closely  allied  to  the  so-called  hour-glass  con- 
traction. Supposing  now  any  cause  produces  a  partial  depression  of 
the  fimdus,  it  is  easy  to  understand  how  it  may  be  grasped  by  the 
contracted  portion,  and  carried  more  and  more  down,  in  the  manner 
of  an  introsusception,  until  complete  inversion  results.  That  such 
partial  paralysis  of  the  uterine  walls  often  exists,  especially  about  the 
placental  site,  was  long  ago  pointed  out  by  Rokitansky  and  other 
pathologists.  This  theory  supposes  the  original  partial  depression  and 
relaxation  of  the  fimdus.  How  this  is 
often  produced  by  mismanagement  of  the 
third  stage  has  already  been  pointed  out ; 
but  even  in  the  absence  of  such  causes,  it 
may  result  from  strong  bearing-down  efforts 
on  the  part  of  the  patient ;  or,  as  Duncan 
holds,  from  the  absence  of  the  retentive 
power  of  the  abdomen.  Indeed,  the  in- 
compatibility of  an  actively  contracted  state 
of  the  fundus  with  the  partial  depression 
which  is  essential,  according  to  both  views, 
for  the  production  of  inversion,  is  the 
strongest  argument  in  favor  of  Duncan's 
theory. 

A  totally  different  view  has  more  recently 
been  sustained  by  Dr.  Taylor,  of  New  York, 
who  maintains  that  "  spontaneous  active  in- 
version of  the  uterus  rests  upon  prolonged 
natural  and  energetic  action  of  the  body 
and  fundus ;  the  cervix,  the  lower  part, 
yielding  first,  is  thus  rolled  out,  or  everted 
or  doubled  up,  as  there  is  no  obstruction  from  the  contractility  of  the 
cervix,  which  is  at  rest  or  functionally  paralyzed ;  the  body  is  gradually, 
sometimes  instantaneously,  forced  lower  and  lower,  or  inverted."1 
That  partial  inversion  may  commence  at  the  cervix  was  pointed  out 


FIG.  156. 


Illustrating  the  commencement 
of  Inversion  at  the  cervix.  (After 
DUNCAN.) 


New  York  Med.  Journ.,  1872,  vol.  xv.  p.  449. 
30 


466  LABOR. 

by  Duncan  in  his  paper,  who  depicts  it  in  the  accompanying  diagram 
(Fig.  156),  and  states  it  to  be  of  not  unfrequent  occurrence.  It  is  not 
impossible  that  occasionally  such  a  state  of  things  should  be  carried  on 
to  complete  inversion.  But  there  are  serious  objections  to  the  accept- 
ance of  Dr.  Taylor's  view  that  such  is  the  principal  cause  of  inversion, 
since  the  process  above  described  would  be  of  necessity  a  slow  and 
long-continued  one,  whereas  nothing  is  more  certain  than  that  inversion 
is  generally  sudden  and  accompanied  by  acute  sym'ptoms  of  shock,  and 
is  often  attended  by  severe  hemorrhage,  which  could  not  occur  when 
such  excessive  contraction  was  taking  place. 

The  treatment  of  inversion  consists  in  restoring  the  organ  to  its 
natural  condition  as  soon  as  possible.  Every  moment's  delay  only 
serves  to  render  restoration  more  difficult,  as  the  inverted  portion 
becomes  swollen  and  strangulated ;  whereas  if  the  attempt  at  reposition 
be  made  immediately,  there  is  generally  comparatively  little  difficulty 
in  effecting  it.  Therefore,  it  is  of  the  utmost  importance  that  no  time 
should  be  lost,  and  that  we  should  not  overlook  a  partial  or  incom- 
plete inversion.  Hence  the  occurrence  of  any  unusual  shock,  pain,  or 
hemorrhage  after  delivery,  without  any  readily  ascertained  cause, 
should  always  lead  to  a  careful  vaginal  examination.  A  want  of 
attention  to  this  rule  has  too  often  resulted  in  the  existence  of  partial 
inversion  being  overlooked  until  its  reduction  was  found  to  be  difficult 
or  impossible. 

In  attempting  to  reduce  a  recent  inversion,  the  inverted  portion  of 
the  uterus  should  be  grasped  in  the  hollow  of  the  hand  and  pushed 
gently  and  firmly  upward  into  its  natural  position,  great  care  being 
taken  to  apply  the  pressure  in  the  proper  axis  of  the  pelvis,  and  to  use 
counter-pressure,  by  the  left  hand,  on  the  abdominal  walls.  Barnes 
lays  stress  on  the  importance  of  directing  the  pressure  toward  one  side 
so  as  to  avoid  the  promontory  of  the  sacrum.  The  common  plan  of 
endeavoring  to  push  back  the  fundus  first  has  been  well  shown  by 
McClintock1  to  have  the  disadvantage  of  increasing  the  bulk  of  the 
mass  that  has  to  be  reduced,  and  he  advises  that,  while  the  fundus  is 
lessened  in  size  by  compression,  we  should,  at  the  same  time,  endeavor 
to  push  up  first  the  part  that  was  less  inverted — that  is  to  say,  the  por- 
tion nearest  the  os  uteri.  Should  this  be  found  impossible,  some  assist- 
ance may  be  derived  from  the  manoeuvre,  recommended  by  Merriman 
and  others,  of  first  endeavoring  to  push  up  one  side  or  Avail  of  the 
uterus,  and  then  the  other,  alternating  the  upward  pressure  from  one 
side  to  the  other  as  we  advance.  It  often  happens,  as  the  hand  is  thus 
applied,  that  the  uterus  somewhat  suddenly  replaces  itself,  sometimes 
with  an  audible  noise,  much  as  an  India-rubber  bottle  would  do  under 
similar  circumstances.  When  reposition  has  taken  place,  the  hand 
should  be  kept  for  some  time  in  the  uterine  cavity  to  excite  tonic  con- 
traction ;  or  a  stream  of  hot  water  at  110°  F.  may  be  injected,  and  if 
that  fails,  a  weak  solution  of  perchloride  of  iron,  so  as  to  cause  tonic 
contraction  of  the  uterus  and  thus  prevent  a  recurrence  of  the  accident, 

It  is  hardly  necessary  to  point  out  how  much  these  manoeuvres  will 

1  Diseases  of  Women,  p.  79. 


INVERSION    OF    THE    UTERUS.  467 

be  facilitated  by  placing  the  patient  fully  under  the  influence  of  an 
anaesthetic. 

There  has  been  much  difference  of  opinion  as  to  the  management  of 
the  placenta  in  cases  in  which  it  is  still  attached  when  inversion  occurs. 
Should  we  remove  it  before  attempting  reposition,  or  should  we  first 
endeavor  to  rein  vert  the  organ  and  subsequently  remove  the  placenta? 
The  removal  of  the  .placenta  certainly  much  diminishes  the  bulk  of 
the  inverted  portion)  and,  therefore,  renders  reposition  easier.  On  the 
other  hand,  if  there  be  much  hemorrhage,  as  is  so  frequently  the  case, 
the  removal  of  the  placenta  may  materially  increase  the  loss  of  blood. 
For  this  reason  most  authorities  recommend  that  an  endeavor  should 
be  made  at  a  reduction  before  peeling  off  the  after-birth.  But  if  any 
delay  or  difficulty  be  experienced  from  the  increased  bulk,  no  time 
should  be  lost,  and  it  is  in  every  way  better  to  remove  the  placenta 
and  endeavor  to  reinvert  the  organ  as  soon  as  possible. 

Supposing  we  met  with  a  case  in  which  the  existence  of  inversion 
has  been  overlooked  for  days,  or  even  for  a  week  or  two,  the  same 
procedure  must  be  adopted  ;  but  the  difficulties  are  much  greater,  and 
the  longer  the  delay  the  greater  they  are  likely  to  be.  Even  no.w, 
however,  a  well-conducted  attempt  at  taxis  is  likely  to  succeed.  Should 
it  fail,  we  must  endeavor  to  overcome  the  difficulty  by  continuous 
pressure  applied  by  means  of  caoutchouc  bags  distended  with  \vater 
and  left  in  the  vagina.  It  is  rarely  that  this  will  fail  in  a  compara- 
tively recent  case,  and  such  only  are  now  under  consideration.  It  is 
likely  that  by  pressure  applied  in  this  way  for  twenty- four  or  forty- 
eight  hours,  and  then  followed  by  taxis,  any  case  detected  before  the 
involution  of  the  uterus  is  completed  may  be  successfully  treated. 

[Spontaneous  Reposition  of  the  Inverted  Uterus. — After  all 
attempts  have  failed  to  replace  an  inverted  uterus  already  too  much 
contracted  to  yield  to  the  pressure  employed,  Nature  sometimes  accom- 
plishes the  work  herself,  as  proved  beyond  question  from  quite  a 
number  of  well-established  cases,  several  of  which  belong  to  our  own 
country.  A  few  years  ago  I  saw  one  of  the  most  remarkable  on  record. 
A  woman  of  twenty-nine,  mother  of  three  children,  miscarried  at  six 
and  a  half  months  from  lifting.  From  the  time  of  her  delivery  she 
was  subject  to  weepings  of  blood,  and  at  times  to  more  or  less  severe 
hemorrhages,  one  of  the  last  of  which  nearly  proved  fatal.  This  con- 
dition of  disease  had  lasted  three  years,  when  Dr.  Walter  F.  Atlee 
was  called  in  to  relieve  her  in  her  worst  hemorrhagic  attack,  and  found 
her  uterus  inverted,  and  a  nodular  growth  upon  the  fundus  which 
gave  out  an  offensive  odor.  Thinking  the  disease  possibly  malignant, 
and  believing,  in  any  event,  that  to  save  the  woman  he  would  be 
obliged  to  remove  the  uterus,  he  called  a  consultation  and  prepared  for 
the  operation ;  but  when  the  patient  was  etherized,  placed  in  the  knee- 
elbow  position,  and  Sims'  speculum  introduced,  behold!  there  was 
nothing  to  be  seen  in  the  vagina  but  a  soft  dilated  cervix,  the  uterus 
having  been  replaced  by  atmospheric  pressure,  aided  perhaps  by  trac- 
tion on  the  uterine  attachments  within.  When  explored,  the  uterus 
was  found  to  be  very  soft  and  thin,  and  to  contain  some  hard  nodular 
masses,  which  on  removal  proved  to  be  portions  of  an  adherent 


468  LABOR. 

placenta.  The  hemorrhage  ceased  upon  the  reposition  and  cleaning 
out  of  the  uterus,  and  the  patient  made  a  good  recovery.  She  has  been 
again  pregnant. 

This  woman  was  anaemic  to  a  marked  degree,  and  her  abdominal 
walls  so  thin  that  a  finger  in  the  uterus  could  readily  be  felt  above  the 
pubes.  There  is  not  the  slightest  doubt  about  the  inversion,  which 
was  proved  to  exist  a  short  time  before  the  change  of  posture  by  Prof. 
Agnew,  who  made  a  finger  in  the  rectum  meet  another  above  the 
pubes,  and  there  was  no  fundus  between  them. 

Two1  cases  are  upon  record  where  reposition  was  the  result  of  falls, 
one  at  eight  months  and  the  other  after  as  many  years.  Drs.  Moehring, 
C.  I).  Meigs,  H.  L.  Hodge,  and  Warrington,  of  this  city,  failed  to 
replace  a  uterus,  and  the  woman  again  became  pregnant  in  about  six 
years,  aborting  with  a  three  months'  foetus  under  the  care  of  Dr. 
Warrington.  Dr.  Meigs  saw  a  second  case  with  Dr.  Levis,  in  which 
there  was  violent  flooding  followed  by  hemorrhages,  which  gradually 
declined.  After  her  return  from  a  journey  West  she  became  pregnant 
and  bore  a  child.  Dr.  John  L.  Atlee,  of  Lancaster,  failed  to  replace 
the  uterus  of  a  woman,  but  she  recovered  spontaneously  and  bore  a 
child  a  year  afterward.2  Dr.  Johnson  F.  Hatch,  of  Kent,  Connecticut, 
reported  a  case  in  a  letter  to  Dr.  C.  D.  Meigs  in  which  inversion 
occurred  spontaneously  fourteen  or  fifteen  hours  after  labor.  After 
being  under  the  care  of  several  physicians,  she  had,  at  the  end  of 
eighteen  months,  two  severe  hemorrhagic  attacks,  after  which  she  im- 
proved, and  finally,  at  the  end  of  two  years  and  nine  months,  bore  a 
child  of  nine  pounds  and  six  ounces. 

In  all  cases  spontaneous  reposition  appears  to  result  from  a  soften- 
ing and  thinning  of  the  uterine  walls  as  the  result  of  anaemia  brought 
on  by  hemorrhages.  This  was  particularly  noticed  by  Boivin  and 
Duges  in  autopsies  of  women  dying  of  repeated  hemorrhages. — ED.] 

P  See  Daillez,  Essai  sur  le  Renversement  de  la  Matrice,  Paris,  1805,  pp.  105-107.] 
[2  Meigs'  Obstetrics,  Philadelphia,  1862,  p.  608.J 


CHAPTER    I. 

INDUCTION  OF  PREMATURE  LABOR. 

History  of  the  Operation. — The  first  of  the  obstetric  operations 
we  have  to  consider  is  the  induction  of  premature  labor,  an  operation 
which,  like  the  use  of  forceps,  was  first  suggested  and  practised  in 
England,  and  the  recognition  of  which,  as  a  legitimate  procedure,  we 
also  chiefly  owe  to  the  labor  of  English  obstetricians,  in  spite  of 
much  opposition  both  at  home  and  abroad.  It  is  not  known  with  cer- 
tainty to  whom  we  owe  the  original  suggestion,  but  we,  are  told  by 
Denman  that  in  the  year  1756  there  was  a  consultation  of  the  most 
eminent  physicians  at  that  time  in  London,  to  consider  the  advantages 
which  might  be  expected  from  the  operation.  The  proposal  met  with 
formal  approval,  and  was  shortly  after  carried  into  practice  by  Dr. 
Macaulay,  the  patient  being  the  wife  of  a  linendraper  in  the  Strand. 
From  that  time  it  has  flourished  in  Great  Britain,  the  sphere  of  its 
application  has  been  largely  increased,  and  it  has  been  the  means  of 
saving  many  mothers  and  children  who  would  otherwise,  in  all  prob- 
ability, have  perished.  On  the  Continent  it  was  long  before  the  opera- 
tion was  sanctioned  or  practised.  Although  recommended  by  some  of 
the  most  eminent  German  practitioners,  it  was  not  actually  performed 
until  the  year  1804.  In  France  the  opposition  was  long-continued 
and  bitter.  Many  of  the  leading  teachers  strongly  denounced  it,  and 
the  Academy  of  Medicine  formally  discountenanced  it  so  late  as  the 
year  1827.  The  objections  were  chiefly  based  on  religious  grounds, 
but  partly,  no  doubt,  on  mistaken  notions  as  to  the  object  proposed  to 
be  gained.  Although  frequently  discussed,  the  operation  was  never 
actually  carried  into  practice  until  the  year  1831,  when  Stoltz  per- 
formed it  with  success.  Since  that  time  opposition  has  greatly  ceased, 
and  it  is  now  employed  and  highly  recommended  by  the  most  distin- 
guished obstetricians  of  the  French  schools. 

Objects  of  the  Operation. — In  inducing  premature  labor,  we  pro- 
pose to  avoid  or  lessen  the  risk  to  which,  in  certain  cases,  the  mother 
is  exposed  by  delivery  at  term,  or  to  save  the  life  of  the  child  which 
might  otherwise  be  endangered.  Hence  the  operation  may  be  indi- 
cated either  on  account  of  the  mother  alone,  or  of  the  child  alone,  or, 
as  not  unfrequently  happens,  of  both  together. 

(469) 


470  OBSTETRIC    OPERATIONS. 

In  by  far  the  largest  number  of  cases  the  operation  is  performed  on 
account  of  defective  proportion  between  the  child  and  the  maternal 
passages,  due  to  some  abnormal  condition  on  the  part  of  the  mother. 
This  want  of  proportion  may  depend  on  the  presence  of  tumors  either 
of  the  uterus  or  growing  from  the  pelvis.  But  most  frequently  it 
arises  from  deformity  of  the  pelvis  (p.  415),  and  it  is  needless  to  repeat 
what  has  been  said  on  that  point.  I  shall  therefore  only  briefly  refer 
to  a  few  more  uncommon  causes  which  occasionally  necessitate  its 
performance. 

One  of  these  is  an  habitually  large,  or  over-firmly  ossified,  foetal 
head.  Should  we  meet  with  a  case  in  which  the  labors  are  always 
extremely  difficult,  and  the  head  apparently  of  unusual  size,  although 
there  is  no  apparent  want  of  space  in  the  pelvis,  the  induction  of  labor 
would  be  perfectly  justifiable,  and  in  all  probability  would  accomplish 
the  desired  object.  In  such  cases  the  full  period  of  delivery  would 
require  to  be  anticipated  by  a  very  short  time.  A  week  or  a  fortnight 
might  make  all  the  difference  between  a  labor  of  extreme  severity  and 
one  of  comparative  ease. 

There  is  a  large  class  of  cases  in  which  the  condition  of  the  mother 
indicates  the  operation.  Many  of  these  have  already  been  considered 
when  treating  of  the  diseases  of  pregnancy.  Amongst  them  may  be 
mentioned  vomiting  which  has  resisted  all  treatment,  and  which  has 
produced  a  state  of  exhaustion  threatening  to  prove  fatal ;  chorea, 
albuminuria,  convulsions,  or  mania;  excessive  anasarca,  ascites,  or 
dyspnoea  connected  with  disease  of  the  heart,  lungs,  or  liver,  which 
may  be,  in  a  great  measure,  caused  by  the  pressure  of  the  enlarged 
uterus  ;  in  fact,  any  condition  or  disease  aifecting  the  mother,  provided 
only  we  are  convinced  that  the  termination  of  pregnancy  would  give 
the  patient  relief,  and  that  its  continuance  would  involve  serious 
danger.  It  need  hardly  be  pointed  out  that  the  induction  of  labor 
for  any  such  causes  involves  great  responsibility,  and  is  decidedly 
open  to  abuse ;  no  practitioner  would,  therefore,  be  justified  in  resort- 
ing to  it — especially  if  the  child  has  not  reached  a  viable  age — 
without  the  most  anxious  consideration.  No  general  rules  can  be  laid 
down.  Each  case  must  be  treated  on  its  own  merits.  It  is  obvious 
that  the  nearer  the  patient  is  to  the  full  period,  the  greater  will  be  the 
chance  of  the  child  surviving,  and  the  less  hesitation  need  then  be  felt 
in  consulting  the  interest  of  the  mother. 

In  another  class  of  cases  the  operation  is  indicated  by  circumstances 
affecting  the  life  of  the  child  alone.  Of  these  the  most  common  are 
those  in  Avhich  the  child  dies,  in  several  successive  pregnancies,  before 
the  termination  of  utero-gestation.  This  is  generally  the  result  of 
fatty,  calcareous,  or  syphilitic  degeneration  of  the  placenta,  which  is 
thus  "rendered  incapable  of  performing  its  functions.  These  changes 
in  the  placenta  seldom  commence  until  a  comparatively  advanced 
period  of  pregnancy ;  so  that  if  labor  be  somewhat  hastened  we  may 
hope  to  enable  the  patient  to  give  birth  to  a  living  and  healthy  child. 
The  experience  of  the  mother  will  indicate  the  period  at  which  the 
death  of  the  foetus  has  formerly  taken  place,  as  she  would  then  have 
appreciated  a  difference  in  her  sensations,  a  diminution  in  the  vigor  Ot* 


INDUCTION    OF    PREMATURE    LABOR.  471 

the  foetal  movements,  a  sense  of  weight  and  coldness,  and  similar 
signs.  For  some  weeks  before  the  time  at  which  this  change  has  been 
experienced,  we  should  carefully  auscultate  the  foetal  heart  from  day 
to  day,  and  in  most  cases  the  approach  of  danger  will  be  indicated 
sufficiently  soon  to  enable  us  to  interfere  with  success,  by  tumultuous 
and  irregular  pulsations,  or  a  failure  in  their  strength  and  frequency. 
On  the  detection  of  these,  or  on  the  mother  feeling  that  the  move- 
ments of  the  child  are  becoming  less  strong,  the  operation  should  at 
once  be  performed.  Simpson  also  induced  premature  labor  with  suc- 
cess in  a  patient  who  had  twice  given  birth  to  hydrocephalic  children. 
In  the  third  pregnancy,  which  he  terminated  before  the  natural  period, 
the  child  was  well  formed  and  healthy. 

Some  obstetricians  have  proposed  to  induce  labor,  with  the  view  of 
saving  the  child,  when  the  mother  was  suffering  from  mortal  disease. 
This  indication  is  however,  so  extremely  doubtful,  from  a  moral  point 
of  view,  that  it  can  hardly  be  considered  as  ever  justifiable. 

Various  Methods  of  Inducing  Labor. — The  means  adopted  for 
the  induction  of  labor  are  very  numerous.  Some  of  them  act  through 
the  maternal  circulation,  as  the  administration  of  ergot  and  other 
oxytocics ;  others  by  their  power  of  exciting  reflex  action,  or  by  in- 
terfering with  the  integrity  of  the  ovum,  or  by  a  combination  of 
both,  as  the  vaginal  douche,  separation  of  the  membranes  from  the 
uterine  walls,  puncture  of  the  ovum,  dilatation  of  the  os,  stimulating 
enemata,  or  irritation  of  the  breasts.  The  former  class  are  never 
employed  in  modern  obstetric  practice.  Of  the  latter,  some  offer 
special  advantages  in  particular  cases,  but  none  are  equally  adapted 
for  all  emergencies.  Often  a  combination  of  more  methods  than  one 
will  be  found  most  useful.  I  shall  mention  the  various  methods  in 
use,  and  discuss  briefly  the  relative  advantages  and  disadvantages  of 
each. 

Puncture  of  Membranes. — The  evacuation  of  the  liquor  amnii  by 
the  puncture  of  the  membranes  was  the  first  method  practised,  and 
was  that  recommended  by  Denman  and  all  the  earlier  writers.  It  is 
the  most  certain  which  can  be  employed,  as  it  never  fails,  sooner  or 
later,  to  induce  uterine  contractions.  There  are,  however,  several  dis- 
advantages connected  with  it  which  are  sufficient  to  centra-indicate  its 
use  in  the  majority  of  cases.  It  is  uncertain  as  regards  the  time  taken 
in  producing  the  desired  effect,  pains  sometimes  coming  on  within  a 
few  hours,  but  occasionally  not  until  several  days  have  elapsed.  The 
contracting  walls  of  the  uterus  press  directly  on  the  body  of  the  child, 
which,  being  frail  and  immature,  is  less  able  to  bear  the  pressure  than 
at  the  full  period  of  pregnancy.  Hence  it  involves  great  risk  to  the 
foetus.  Besides,  the  escape  of  the  water  does  away  with  the  fluid 
wedge  so  useful  in  dilating  the  os,  and  should  version  be  necessary 
from  malpresentation — a  complication  more  likely  to  occur  than  in 
natural  labor — the  operation  would  have  to  be  performed  under  very 
unfavorable  conditions.  These  objections  are  sufficient  to  justify  the 
ordinary  opinion  that  this  procedure  should  not  be  adopted  unless 
other  means  have  been  tried  and  failed.  Every  now  and  then  cases 
are  met  with  in  which  it  is  extremly  difficult  to  arouse  the  uterus  to 


472  OBSTETEIC    OPERATION'S. 

action,  and  under  such  circumstances,  in  spite  of  its  drawbacks,  this 
method  will  be  found  to  be  very  valuable.  When  the  operation  has 
to  be  performed  before  the  child  is  viable — that  is,  before  the  seventh 
month — these  objections  do  not  hold,  and  then  it  is  the  simplest  and 
readiest  procedure  we  can  adopt.  Indeed,  in  producing  early  abortion, 
no  other  is  practicable.  The  operation  itself  is  most  simple,  requiring 
only  a  quill,  stiletted  catheter,  or  other  suitable  instrument,  to  be 
passed  up  to  the  os,  carefully  guarded  by  the  fingers  of  the  left  hand 
previously  introduced,  and  to  be  pressed  against  the  membranes  until 
perforation  is  accomplished.  Meissner,  of  Leipzig,  has  proposed  as  a 
modification  of  this  plan,  that  the  membrane  should  be  punctured 
obliquely,  three  or  four  inches  above  the  os,  so  as  to  admit  of  a  gradual 
and  partial  escape  of  the  amuiotic  fluid,  thus  lessening  the  risk  to  the 
child  from  pressure  by  the  uterus.  For  this  purpose  he  employed  a 
curved  silver  canula  containing  a  small  trocar,  which  can  be  pro- 
jected after  introduction.  The  risk  of  injuring  the  uterus  by  such  an 
instrument  would  be  considerable,  and  we  have  other  and  better  means 
at  our  command  which  render  it  unnecessary.  When  we  require  to 
produce  early  abortion,  it  would  be  well  not  to  attempt  to  puncture 
the  membranes  with  a  sharp-pointed  instrument.  The  object  can  be 
effected  with  certainty  and  greater  safety  by  passing  an  ordinary 
uterine  sound  through  the  os  and  turning  it  around  once  or  twice. 

Administration  of  Oxytocics. — The  administration  of  ergot  of 
-rye,  either  alone  or  combined  with  borax  and  cinnamon,  has  been 
sometimes  resorted  to.  This  practice  has  been  principally  advocated 
by  Ramsbotham,  who  was  in  the  habit  of  exhibiting  scruple  doses  of 
the  powdered  ergot  every  fourth  hour  until  delivery  took  place. 
Sometimes  he  found  that  as  many  as  thirty  or  forty  doses  were  re- 
quired to  effect  the  object ;  occasionally  labor  commenced  after  a  single 
dose.  Finding  that  the  infantile  mortality  was  very  great  when  this 
method  was  followed,  he  modified  it  and  administered  two  or  three 
doses  only,  and,  if  these  proved  insufficient,  he  punctured  the  mem- 
branes. There  can  be  no  doubt  that  ergot  possesses  the  power  of  in- 
ducing uterine  contractions.  The  risk  to  the  child  is,  however,  quite 
as  great  as  when  the  membranes  are  punctured ;  for  not  only  is  it 
subject  to  injurious  pressure  from  the  tumultuous  and  irregular  con- 
tractions which  the  ergot  produces,  but  the  drug  itself,  when  given  in 
large  doses,  seems  to  exert  a  poisonous  influence  on  the  foatus.  For 
these  reasons  ergot  may  properly  be  excluded  froni  the  available 
means  of  inducing  labor. 

Methods  Acting  Indirectly  on  the  Uterus. — Various  methods 
have  been  recommended  which  act  indirectly  on  the  uterus,  the  source 
of  irritation  being  at  a  distance.  Thus  D'Outrepont  used  frequently 
repeated  abdominal  frictions  and  tight  bandages.  Scanzoni,  remem- 
bering the  intimate  connection  between  the  mammae  and  uterus,  and 
the  tendency  which  irritation  of  the  former  lias  to  induce  contraction 
of  the  latter,  recommended  the  frequent  application  of  cupping-glasses 
to  the  breasts.  Radford  and  others  have  employed  galvanism. 
Stimulating  enemata  have  been  employed.  All  these  methods  have 
occasionally  proved  successful,  and,  unlike  the  former  plans  we  have 


INDUCTION    OF    PREMATURE    LAROR.  473 

mentioned,  they  are  not  attended  by  any  special  risk  to  the  child. 
They  are,  however,  much  too  uncertain  to  be  relied  on,  besides  being 
irksome  both  to  the  patient  and  practitioner. 

The  artificial  dilatation  of  the  os  uteri  in  imitation  of  its  natural 
opening  in  labor  was  first  practised  by  Kliige.  He  was  in  the  habit 
of  passing  within  the  os  a  tent  made  of  compressed  sponge,  and  allow- 
ing it  to  dilate  by  imbibition  of  fluid.  If  labor  was  not  provoked 
within  twenty-four  hours  he  removed  it  and  introduced  one  of  larger 
dimensions,  changing  it  as  often  as  was  necessary  until  his  object  was 
accomplished.  Although  this  operation  seldom  failed  to  induce  labor, 
it  had  the  disadvantage  of  occupying  an  indefinite  time,  and  the  irrita^ 
tion  produced  was  often  painful  and  annoying.  Dr.  Keiller,  of  Edin- 
burgh, was  the  first  to  suggest  caoutchouc  bags,  distended  by  air,  as  a 
means  of  dilating  the  os.  This  plan  has  been  perfected  by  Dr.  Robert 
Barnes  in  his  well-known  dilators,  which  are  of  great  use  in  many 
cases  in  which  artificial  dilatation  of  the  cervix  is  necessary.  They 
consist  of  a  series  of  India-rubber  bags  of  various  sizes  with  a  tube 
attached  (Fig.  1 57),  through  which  water  can  be  injected  by  an  ordinary 
Higginson's  syringe.  They  have  a  small  pouch  fixed  externally,  in 
which  a  sound  can  be  placed,  so  as  to  facilitate  their 
introduction.  When  distended  with  water  the  bags 
assume  somewhat  of  a  fiddle  shape,  bulging  at  both 
extremities,  which  insures  their  being  retained  within 
the  os.  When  first  introduced  into  practice  as  a 
means  of  inducing  labor,  it  was  thought  that  this 
method  gave  a  complete  control  over  the  process,  so 
that  it  could  be  concluded  within  a  definite  time  at 
the  will  of  the  operator.  The  experience  of  those 
who  have  used  it  much  has  certainly  not  justified 
this  anticipation.  It  is  true  that  occasionally  con- 
tractions supervene  within  a  few  hours  after  dilata- 
tion has  been  commenced ;  but,  on  the  other  hand, 
the  uterus  often  responds  very  imperfectly  to  this 
kind  of  stimulus,  and  the  bags  may  be  inserted  for 
many  consecutive  hours  without  the  desired  result 

„     ,  ,  ,     .  Barnes  bag  for  dilat. 

supervening,  the  puncture  of  the  membranes  being  ing  the  cervix. 
eventually  necessary  in  order  to  hasten  the  process. 
Indeed,  my  o^vn  experience  would  lead  me'to  the  conclusion  that,  as  a 
means  of  evoking  uterine  contraction,  cervical  dilatation  is  very  un- 
satisfactory. Dr.  Barnes  himself  has  evidently  seen  reason  to  modify 
his  original  views,  for  while  he  at  first  talked  of  the  bags  as  enabling 
us  to  induce  labor  with  certainty  at  a  given  time,  he  has  since  recom- 
mended that  uterine  action  should  be  first  provoked  by  other  means, 
the  dilators  being  subsequently  used  to  accelerate  the  labor  thus 
brought  on.  The  bags  thus  employed  find,  as  I  believe,  their  most 
useful  and  a  very  valuable  application ;  but  when  used  in  this  way 
they  cannot  be  considered  a  means  of  originating  uterine  action.  A 
subsidiary  objection  to  the  bags  is  the  risk  of  displacing  the  presenting 
part.  I  have,  for  example,  introduced  them  when  the  head  was  pre- 
senting, and,  on  their  removal,  found  the  shoulder  lying  over  the  os. 


474 


OBSTETRIC    OPERATIONS. 


It  is  not  difficult  to  understand  how  the  continuous  pressure  of  a  dis- 
tended bag  in  the  internal  os  might  easily  push  away  the  head,  which 
is  so  readily  movable  so  long  as  the  membranes  are  unruptured.  Still, 
if  labor  be  in  progress,  and  the  os  insufficiently  dilated,  the  possibility 
of  this  occurrence  is  not  a  sufficient  reason  for  not  availing  ourselves 
of  the  undoubtedly  valuable  assistance  which  the  dilators  are  capable 


FIG.  158. 


Champetier  de  Ribes'  dilator  and  introducing  forceps. 

of  giving.  A  modified  form  of  dilator,  invented  by  Champetier  de 
Ribes,1  has  been  highly  spoken  of  and  promises  to  be  useful  (Fig.  158). 
It  differs  from  Barnes's  instrument  in  being  conical,  in  being  made  of 
inelastic  waterproof  silk,  and  in  being  much  larger,  so  that  when  the 
expanded  bag  has  passed  through  the  cervical  canal,  the  child  can  be 
quickly  delivered.  It  is  introduced  by  special  forceps,  and  left  until 

1  Annal.  de  Gyn.,  1888,  p.  401. 


INDUCTION    OF    PREMATURE    LABOR.  475 

it  is  expelled  by  the  pains.  The  average  time  in  which  this  happened 
in  sixteen  cases  was  eight  hours. 

Separation  of  the  Membranes. — Some  processes  for  inducing 
labor  act  directly  on  the  ovum  by  separating  the  membranes,  to  a 
greater  or  less  extent,  from  the  uterine  walls.  The  first  procedure  of 
the  kind  was  recommended  by  Dr.  Hamilton,  of  Edinburgh,  and  con- 
sisted in  the  gradual  separation  of  the  membranes  for  one  or  two 
inches  all  round  the  lower  segment  of  the  uterus.  To  reach  them  the 
finger  had  to  be  gently  insinuated  into  the  interior  of  the  os,  which 
was  gradually  dilated  to  a  sufficient  extent  by  a  series  of  successive 
operations,  repeated  at  intervals  of  three  or  four  hours.  When  this 
had  been  accomplished,  the  forefinger  was  inserted  and  swept  round 
between  the  membranes  and  the  uterus,  but  it  was  frequently  found 
necessary  to  introduce  the  greater  part  of  the  hand  to  effect  the  object, 
and  sometimes  even  this  was  not  sufficient  and  a  female  catheter  or 
other  instrument  had  to  be  used  for  the  purpose.  The  method  was 
generally  successful  in  bringing  on  labor,  but  it  now  and  then  failed, 
even  in  Dr.  Hamilton's  hands.  It  is  certainly  based  on  correct  prin- 
ciples, but  it  is  tedious  and  painful,  both  to  the  practitioner  and  the 
patient,  and  very  uncertain  in  its  time  of  action.  For  these  reasons 
it  has  never  been  much  practised. 

Vaginal  and  Uterine  Douches. — In  the  year  1836,  Kiwisch  sug- 
gested a  plan  which,  from  its  simplicity,  has  met  with  much  approval. 
It  consists  in  projecting,  at  intervals,  a  stream  of  warm  or  cold  Avater 
against  the  os  uteri.  Its  action  is  doubtless  complex.  Kiwisch  him- 
self believed  that  relaxation  of  the  soft  parts,  through  the  imbibition 
of  water,  was  the  determining  cause  of  labor.  Simpson  found  that 
the  method  failed  unless  the  water  mechanically  separated  the  mem- 
branes from  the  uterine  walls.  Besides  this  effect  it  probably  directly 
induces  reflex  action  by  distending  the  vagina  and  dilating  the  os.  In 
using  it,  it  has  been  customary  to  administer  a  douche  twice  daily, 
and  more  frequently  if  rapid  effects  be  desired.  The  number  required 
varies  in  different  cases.  The  largest  number  Kiwisch  found  it  neces- 
sary to  use  was  seventeen,  the  smallest  five.  The  average  time  that 
elapses  before  labor  sets  in  is  four  days.  Hence  the  method  is  obvi- 
ously useless  when  rapid  delivery  is  required. 

Dr.  Cohen,  of  Hamburg,  introduced  an  important  modification  of 
the  process,  which  has  been  considerably  practised.  It  consists  in 
passing  a  silver  or  gum-elastic  catheter  some  inches  within  the  os, 
between  the  membranes  and  the  uterine  walls,  and  injecting  the  fluid 
through  it  directly  into  the  cavity  of  the  uterus.  He  used  creasote 
or  tar  water,  and  injected  without  stopping  until  the  patient  com- 
plained of  a  feeling  of  distention.  Others  have  found  the  plan 
equally  efficacious  when  they  only  employed  a  small  quantity  of  plain 
water,  such  as  seven  or  eight  ounces.  Professor  Lazarewiteh,  of  St. 
Petersburg,  is  a  strong  advocate  of  this  method.  He  believes  that 
uterine  action  is  evoked  much  more  rapidly  and  certainly  if  the  water 
bo  injected  near  the  fundus,  and  he  has  contrived  an  instrument  for 
the  purpose,  with  a  long  metallic  nozzle. 

Dangers  of  these  Plans. — So  many  fatal  cases  have  followed  these 


476  OBSTETRIC    OPERATIONS. 

methods,  that  it  cannot  be  doubted  that,  in  spite  of  their  certainty  and 
simplicity,  there  is  an  element  of  risk  in  them  that  should  not  be 
overlooked.  Many  of  these  are  recorded  in  Barnes's  work,  and  he 
comes  to  the  conclusion,  which  the  facts  unquestionably  justify,  that 
"  the  douche,  whether  vaginal  or  intra-uterme,  ought  to  be  absolutely 
condemned  as  a  means  of  inducing  labor."  The  precise  reason  of  the 
danger  is  not  very  obvious.  Sudden  stretching  of  the  uterine  walls, 
producing  shock,  has  been  supposed  to  have  caused  it ;  but  in  many 
of  the  fatal  cases  the  symptoms  have  been  rather  those  attending  the 
passage  of  air  into  the  veins,  and  it  is  easy  to  understand  how  air  may 
have  been  introduced  in  this  way  into  the  large  uterine  sinuses. 

Simpson  and  Scanzoni  have  both  tried  with  success  the  injection  of 
carbonic  acid  gas  into  the  vagina.  Fatal  results  have,  however,  fol- 
lowed its  employment,  and  Simpson  expressed  an  opinion  that  the 
experiment  should  not  be  repeated. 

Simpson  originally  induced  labor  by  passing  the  uterine  sound 
within  the  os,  and  up  toward  the  fundus,  and,  when  it  had  been  in- 
serted to  a  sufficient  extent,  moving  it  slightly  from  side  to  side.  He 
was  led  to  adopt  this  procedure  in  the  belief  that  we  might  thus 
closely  imitate  the  separation  of  the  decidua,  which  occurs  previous  to 
labor  at  term.  Uterine  contractions  were  induced  with  certainty  and 
ease,  but  it  wras  found  impossible  to  foretell  what  time  might  elapse 
between  the  commencement  of  labor  and  the  operation,  which  had 
frequently  to  be  performed  more  than  once.  He  subsequently  modi- 
fied this  procedure  by  introducing  a  flexible  male  catheter,  without  a 
stilette,  which  he  allowed  to  remain  in  the  uterus  until  contractions 
were  excited.  This  plan  is  much  used  in  Germany,  and  is  now  that 
which  is  also  most  frequently  adopted  in  England.  It  is  simple 
and  very  efficacious,  pains  coming  on  almost  invariably  within 
twenty-four  hours  after  the  catheter  or  bougie  is  introduced.  A  theo- 
retical objection  is  the  possibility  of  the  catheter  separating  a  portion 
of  the  placenta  and  giving  rise  to  hemorrhage;  but  in  practice  this 
has  not  been  found  to  occur,  and  the  risk  might  generally  be  avoided 
by  introducing  the  catheter  at  a  distance  from  the  placenta,  the  prob- 
able situation  of  which  has  been  ascertained  by  auscultation.  The 
more  deeply  the  catheter  is  introduced,  the  more  certain  and  rapid  is 
its  effect,  and  not  less  than  seven  inches  should  be  pushed  up  within 
the  os.  It  is  not  always  easy  to  insert  it  so  far,  especially  if  a  flexible 
catheter  be  used,  which  is  apt  to  be  too  pliable  to  pass  upward  with 
ease.  A  solid  bougie — male  urethral  bougie — should,  therefore,  be 
employed,  or  a  hollow  bougie  containing  a  wire  stilette,  and  I  have 
found  its  introduction  greatly  facilitated  by  anaesthetizing  the  patient 
and  passing  the  greater  part  of  the  hand  into  the  vagina.  In  this 
way  it  can  be  pushed  in  very  gently  and  without  any  risk  of  injury 
to  the  uterus.  Previous  to  introducing  the  bougie  it  should  be 
thoroughly  asepticized  by  the  1  : 1000  solution,  with  which  the  vagina 
should  also  be  well  douched.  There  is  some  chance  of  rupturing  the 
membranes  while  pushing  it  upward.  This  accident,  indeed,  cannot 
always  be  avoided,  even  when  the  greatest  care  is  taken ;  but  when  it 
occurs,  the  puncture  will  be  at  a  distance  from  the  os,  so  that  a  small 


INDUCTION    OF    PREMATURE    LABOR.  477 

portion  only  of  the  liquor  amnii  will  escape,  and  this  can  scarcely  be 
considered  a  serious  objection.  It  is  always  an  advantage  to  allow  the 
pains  to  come  on  gradually,  and  in  imitation  of  natural  labor.  There- 
fore, if,  after  the  bougie  lias  been  inserted  for  a  sufficient  time,  uterine 
contractions  come  on  sufficiently  strongly,  we  may  leave  the  case  to  be 
terminated  naturally ;  or,  if  they  be  comparatively  feeble,  we  may 
resort  to  accelerative  procedures,  viz.,  dilatation  of  the  cervix  by  the 
fluid  bags,  and  subsequently  the  puncture  of  the  membranes.  In 
this  way  we  have  the  labor  completely  under  control ;  and  I  believe 
this  method  will  commend  itself  to  those  who  have  experience  of  it, 
as  the  simplest  and  most  certain  mode  of  inducing  labor  yet  known, 
and  the  one  most  closely  imitating  the  natural  process.  Of  late  I 
have  been  in  the  habit  of  combining  dilatation  of  the  cervix  with  this 
method,  by  means  of  a  well-carbolized  sponge  tent  passed  into  the 
cervix  after  the  bougie  is  in  position.  In  ten  or  twelve  hours,  when 
the  tent  and  bougie  are  removed,  the  cervix  is  found  well  dilated  and 
ready  for  the  passage  of  the  child. 

[The  most  serious  objection  to  the  induction  of  premature  labor  is 
the  frightful  infantile  mortality  :  that  of  the  mothers  is  quite  low  in 
skilful  hands.  The  late  Dr.  Cesare  Belluzzi,  of  Bologna,  recorded  112 
cases,  with  8  deaths  of  women  and  15  of  the  fo3tuses — 42  patients  were 
treated  in  his  private  practice,  and  70  in  the  Maternity  of  Bologna. 
In  9  patients  labor  was  induced  because  of  disease  in  the  mother ;  in 
1  it  was  brought  on  because  the  foetus  had  usually  died  in  the  ninth 
month  of  former  pregnancies ;  and  in  102  the  pelvis  was  contracted. 
Of  these  102,  6  died — 3  out  of  38  in  private  practice,  and  3  out  of  64 
in  the  hospital.  Of  the  9  women  operated  upon  because  of  serious 
disease,  7  recovered. .  35  out  of  42  infants  were  delivered  alive  in 
private  practice,  and  62  out  of  70  in  the  Maternity.  The  prolonged 
vitality  of  the  fcetus  is  largely  dependent  upon  the  period  of  gestation 
which  is  chosen  for  the  operation  ;  the  later  the  delivery,  the  better  is 
the  prospect  of  ultimate  safety.  But  a  small  proportion  of  the  chil- 
dren reach  maturity.  Of  32  delivered  alive  in  hospital  in  a  period  of 
less  than  ten  years  under  Dr.  Belluzzi,  27  were  dead  before  the  expi- 
ration of  the  first  year,  and  29  in  all  within  two  years  of  birth. — ED.] 

It  should  not  be  forgotten  that  the  child  is  immature,  and  that 
unusual  care  is  likely  to  be  required  to  rear  it  successfully.  Indeed, 
the  large  infantile  mortality  after  the  induction  of  premature  labor 
forms  the  most  serious  objection  to  the  operation.  Thus  Ludwig 
Winckel1  published  twenty-five  cases  of  induced  labor  on  account  of 
contracted  pelvis.  The  mothers  all  recovered,  but  fourteen  of  the 
children  were  stillborn;  of  the  thirteen  born  alive,  only  seven  survived 
a  fortnight.  If,  therefore,  we  decide  on  the  operation,  the  parents 
should  be  warned  of  the  risks  run  by  the  child,  although  these  are  not 
of  themselves  a  sufficient  contra-indication  to  its  adoption  in  suitable 
cases.  We  should,  therefore,  be  careful  to  have  at  hand  all  the  usual 
means  of  resuscitation  ;  and,  as  the  mother  may  not  be  able  to  nurse 
at  once,  it  would  be  a  good  precaution  to  have  a  healthy  wet-nurse  in 
readiness. 

»  See  Harris's  note  to  6th  American  edition. 


478 


OBSTETRIC    OPERATIONS. 


It  is  a  matter  of  great  importance  to  maintain  the  animal  heat  of 
premature  children.  For  this  purpose  they  are  generally  wrapped  in 
cotton-wool  and  kept  near  the  fire,  but  this  is  dirty  and  unsatisfactory. 
A  far  better  and  more  hopeful  procedure  is  to  place  the  infant  in  an 
incubator  or  couveuse,1  maintained  at  a  uniform  heat  by  means  of  a 
lamp,  such  as  was  first  introduced  by  Taruier.  I  used  a  modification 
of  this  apparatus,  such  as  is  here  figured  (Fig.  159),  in  a  case  in  which 
the  foetus  could,  at  the  most,  have  been  at  the  sixth  month,  keeping  it 
for  three  months  in  the  heated  chamber,  at  a  temperature  varying 


FIG.  159. 


Hearson's  thermostatic  nurse,  c.  Tank  of  warm  water  interposed  between  upper  and  lower 
compartments  (A  and  B).  D  D.  Slips  of  wood  supporting  cradle,  s.  Capsule  containing  a  liquid 
which  boils  at  the  temperature  at  which  it  is  desired  to  keep  the  chamber,  A.  From  the  centre  of 
the  capsule,  s,  a  stiff  wire  passes  out  through  the  top  of  the  apparatus,  where  it  comes  into  contact 
with  a  light  lever,  v,  which  is  hinged  at  F.  From  the  free  end  of  this  lever  hangs  a  damper  (w), 
which  rests  on  the  top  of  the  chimney  under  which  the  flame  burns.  If  the  temperature  in  the 
compartment  A  rises  too  high,  the  fluid  in  the  capsule  (s)  boils  and  expands  the  capsule,  thus 
raising  the  wire  rod,  which,  acting  on  the  lever  v,  at  once  lifts  the  damper  (w)  off  the  chimney, 
allowing  the  heat  from  the  flame  to  escape  by  that  outlet  and  preventing  the  further  heating  of 
the  water.  M.  Aperture  for  entrance  of  air.  o.  Tray  containing  water.  The  centre  of  this  tray  is 
raised  in  the  form  of  a  cap  (p),  which  fits  over  the  aperture  M,  through  which  the  air  enters.  It  is 
perforated  all  around  its  sides,  so  that  the  air  passes  through  it  horizontally,  as  shown  by  the 
arrows,  instead  of  rising  vertically.  Another  tray  (x)  of  very  coarsely  perforated  zinc,  somewhat 
smaller  than  the  first,  is  turned  upside  down  within  it,  and  over  this  is  fitted  the  coarse  canvas  (N), 
the  edges  of  which  are  tucked  into  the  water  all  around.  Thus  the  air  entering  is  constantly 
moistened  as  well  as  heated.  R  R.  Flue  shaped  like  the  letter  U,  through  which  the  heated  air 
from  the  flame  passes,  so  as  to  twice  traverse  the  length  of  the.  water-tank,  and  thus  keep  the  water 
heated.  In  the  top  of  the  apparatus  is  a  glass  window  through  which  the  infant  is  kept  in  view. 
If  a  higher  temperature  than  the  boiling-point  of  the  liquid  withiu  the  capsule  be  desired,  this 
can  be  obtained  by  moving  the  weight,  T,  along  the  lever  toward  the  end  to  which  the  damper  is 
attached. 

from  80°  to  90°  F.,  with  a  most  satisfactory  result.  The  apparatus  is, 
however,  costly,  and  requires  a  great  deal  of  attention  and  supervision, 
so  that  it  is  clearly  only  suitable  for  use  in  maternity  hospitals  or  in 
the  houses  of  such  patients  as  are  able  to  incur  the  necessary  expense. 

i  Auvard :  "  De  la  Couveuse  pour  Enfants,"  Arch,  de  Tocologie,  Oct.  1883,  p.  577. 


• 

TURNING.  479 


CHAPTER   II. 

TURNING. 

History  of  the  Operation. — Turning,  by  which  we  mean  the  alter- 
ation of  the  position  of  the  fetus,  and  the  substitution  of  some  other 
portion  of  the  body  for  that  originally  presenting,  is  one  of  the  most 
important  of  obstetric  operations,  and  merits  careful  study.  It  is  also 
one  of  the  most  ancient,  and  was  evidently  known  to  the  Greek  and 
Roman  physicians.  Up  to  the  fifteenth  century,  cephalic  version — 
that  in  which  the  head  of  the  foetus  is  brought  over  the  os  uteri — was 
almost  exclusively  practised,  when  Par6  and  his  pupil  Guillemeau  taught 
the  propriety  of  bringing  the  feet  down  first.  It  was  by  the  latter 
physician  especially  that  the  steps  of  the  operation  were  clearly  defined ; 
and  the  French  have  undoubtedly  the  merit  both  of  perfecting  its  per- 
formance and  of  establishing  the  indications  which  should  lead  to  its 
use.  Indeed,  it  was  then  much  more  frequently  performed  than  in 
later  times,  since  no  other  means  of  eifecting  artificial  delivery  were 
known  which  did  not  involve  the  death  of  the  child;  and  practitioners, 
doubtless,  acquired  great  skill  in  its  performance,  and  were  inclined  to 
overrate  its  importance  and  extend  its  use  to  unsuitable  cases.  An 
opposite  error  was  fallen  into  after  the  invention  of  the  forceps,  which 
for  a  time  led  to  the  abandonment  of  turning  in  certain  conditions  for 
which  it  was  well  adapted,  and  in  which  it  has  only  of  late  years  been 
again  practised. 

Cephalic  version  has,  since  Pare  wrote,  been  recommended  and 
practised  from  time  to  time,  but  the  difficulty  of  performing  it  satis- 
factorily was  so  great  that  it  never  became  an  established  operation. 
Dr.  Braxton  Hicks  has  perfected  a  method  by  which  it  can  be  accom- 
plished with  greater  ease  and  certainty,  and  which  renders  it  a  legiti- 
mate and  satisfactory  resort  in  suitable  cases.  To  him  we  are  also 
indebted  for  introducing  a  method  of  turning  without  passing  the 
entire  hand  into  the  cavity  of  the  uterus,  which,  under  favorable 
circumstances,  is  not  only  easy  of  performance,  but  deprives  the  oper- 
ation of  one  of  its  greatest  dangers. 

The  possibility  of  effecting  version  by  external  manipulation  has 
been  long  known,  and  was  distinctly  referred  to  and  recommended  by 
Dr.  John  Pechey1  so  far  back  as  the  year  1698.  Since  that  time  it 
has  been  strongly  advocated  by  Wigand  and  his  followers ;  and  vari- 
ous authors  in  England,  notably  Sir  James  Simpson,  have  referred 
to  the  advantage  to  be  derived  from  external  manipulation  assisting 
the  hand  in  the  interior  of  the  uterus.  In  1854  Dr.  Wright,  of 

1  The  Complete  Midwife's  Practice,  p.  142. 


480  OBSTETRIC    OPERATIONS. 

Cincinnati,  advocated  the  application  of  the  bimanual  method  in  arm 
and  shoulder  presentations,  chiefly  with  the  view  of  effecting  cephalic 
version.  To  Dr.  Hicks,  however,  incoiitestably  belongs  the  merit  of 
having  been  the  first  distinctly  to  show  the  possibility  of  effecting 
complete  version  in  all  cases  in  which  the  operation  is  indicated  by 
combined  external  and  internal  manipulation,  of  laying  down  definite 
rules  for  its  practice,  and  of  thus  popularizing  one  of  the  greatest  im- 
provements in  modern  midwifery. 

The  operation  is  entirely  dependent  for  success  on  the  fact  that  the 
child  in  ute.ro  is  freely  movable,  and  that  its  position  may  be  artificially 
altered  with  facility.  As  long  as  the  membranes  are  unruptured  and 
the  foetus  is  floating  in  the  surrounding  fluid  medium,  it  is  liable  to 
constant  changes  in  position,  as  may  be  readily  demonstrated  in  the 
latter  months  of  pregnancy ;  and  the  operation,  under  these  circum- 
stances, may  be  performed  with  the  greatest  facility.  Shortly  after  the 
liquor  amnii  has  escaped  there  is  still,  as  a  rule,  no  great  difficulty  in 
effecting  version ;  but,  as  the  body  is  no  longer  floating  in  the  sur- 
rounding liquid,  its  rotation  must  necessarily  be  attended  with  some 
increased  risk  of  injury  to  the  uterus.  If  the  liquor  amuii  has  been 
long  evacuated  and  the  muscular  structure  of  the  uterus  is  strongly 
contracted,  the  foetus  may  be  so  firmly  fixed  that  any  attempt  to  move 
it  is  surrounded  with  the  greatest  difficulties,  and  may  even  fail  en- 
tirely or  be  attended  with  such  risks  to  the  maternal  structures  as  to 
be  quite  unjustifiable. 

Version  may  be  required  either  on  account  of  the  mother  or  child 
alone ;  or  it  may  be  indicated  by  some  condition  imperilling  both,  and 
rendering  immediate  delivery  necessary.  The  chief  cases  in  which 
it  is  resorted  to,  are  those  of  transverse  presentation,  where  it  is 
absolutely  essential ;  accidental  or  unavoidable  hemorrhage ;  certain 
cases  of  contracted  pelvis ;  and  some  complications,  especially  prolapse 
of  the  funis.  The  special  indications  for  the  operation  have  been 
separately  discussed  under  these  subjects. 

Statistics  and  Dangers  of  the  Operation. — The  ordinary  statis- 
tical tables  cannot  be  depended  on  as  giving  any  reliable  results  as  to 
the  risks  of  the  operation.  Taking  all  cases  together,  Dr.  Churchill 
estimated  the  maternal  mortality  at  one  in  sixteen,  and  the  infantile  as 
one  in  three.  Like  all  similar  statistics,  they  are  open  to  the  objection 
of  not  distinguishing  between  the  results  of  the  operation  itself  and 
of  the  cause  which  necessitated  interference.  Still,  they  are  sufficient 
to  show  that  the  operation  is  not  free  from  grave  hazards,  and  that  it 
must  not  be  undertaken  without  due  reflection.  The  principal  dangers 
will  be  discussed  as  we  proceed.  It  may  suffice  to  mention  here  that 
those  to  the  mother  must  vary  with  the  period  at  which  the  operation 
is  undertaken.  If  version  be  performed  early,  before  the  rupture  of 
the  membranes,  or,  in  favorable  cases,  without  the  introduction  of  the 
hand  into  the  interior  of  the  uterus,  the  risk  must  of  course  be  in- 
finitely less  than  in  those  more  formidable  cases  in  which  the  waters 
have  long  escaped,  and  the  hand  and  arm  have  to  be  passed  into  an 
irritable  and  contracted  uterus.  But  even  in  the  most  unfavorable 
cases  accidents  may  be  avoided  if  the  operator  bears  constantly  in  mind 


TURNING.  481 

that  the  principal  danger  consists  iii  laceration  of  the  uterus  or  vagina 
from  undue  force  being  employed,  or  from  the  hand  and  arm  not  being 
introduced  in  the  axis  of  the  .passages.  There  is  no  operation  in  which 
gentleness,  absence  of  all  hurry,  and  complete  presence  of  mind  are 
so  essential.  A  certain  number  of  cases  end  fatally  from  shock  or 
exhaustion,  or  from  subsequent  complications.  As  regards  the  child 
the  mortality  is  little,  if  at  all,  greater  than  in  original  breech  and 
footling  presentations.  Nor  is  there  any  good  reason  why  it  should  be 
so,  seeing  that  cases  of  turning,  after  the  feet  are  brought  through  the 
os,  are  virtually  reduced  to  those  of  feet  presentation,  and  that  the 
mere  version,  if  effected  sufficiently  soon,  is  not  likely  to  add  materially 
to  the  risk  to  which  the  child  is  exposed. 

The  possibility  of  effecting  version  by  external  manipulation  has  been 
recognized  by  various  authors,  and  was  made  the  subject  of  an  excellent 
thesis  by  Wigand,  who  clearly  described  the  manner  of  performing  the 
operation.  In  spite  of  the  manifest  advantages  of  the  procedure,  and 
the  extreme  facility  with  which  it  can  be  accomplished  in  suitable 
cases,  it  has  by  no  means  become  the  established  custom  to  trust  to  it, 
and  probably  most  practitioners  have  never  attempted  it,  even  under 
the  most  favorable  conditions.  The  possibility  of  the  operation  is 
based  on  the  extreme  mobility  of  the  foetus,  before  the  membranes  are 
ruptured.  After  the  waters  have  escaped,  the  uterine  walls  embrace 
the  foetus  more  or  less  closely,  and  version  can  no  longer  be  readily 
performed  in  this  manner. 

It  may,  therefore,  be  laid  down  as  a  rule  that  it  should  only  be 
attempted  when  the  abnormal  position  of  the  foetus  is  detected  before 
labor  has  commenced,  or  in  the  early  stage  of  labor,  when  the  mem- 
branes are  unruptured.  It  is  also  unsuitable  for  any  but  transverse 
presentations,  for  it  is  not  meant  to  effect  complete  evolution  of  the 
foetus,  but  only  to  substitute  the  head  for  the  upper  extremity.  It  is 
useless  whenever  rapid  delivery  is  indicated,  for,  after  the  head  is 
brought  over  the  brim,  the  conclusion  of  the  case  must  be  left  to  the 
natural  powers. 

The  manner  of  detecting  the  presentation  by  palpation  has  been 
already  described  (p.  129),  and  the  success  of  the  operation  depends  on 
our  being  able  to  ascertain  the  positions  of  the  head  and  breech  through 
the  uterine  walls.  Should  labor  have  commenced,  and  the  os  be  dilated, 
the  transverse  presentation  may  be  also  made  out  by  vaginal  examina- 
tion. Should  the  abnormal  presentation  be  detected  before  labor  has 
actually  begun,  it  is,  in  most  cases,  easy  enough  to  alter  it,  and  to  bring 
the  foetus  into  the  longitudinal  axis  of  the  uterine  cavity.  Pinard1 
recommends  that  after  this  has  been  done  the  foetus  should  be  main- 
tained in  position  by  a  Avell-fitting  elastic  abdominal  belt.  It  is  seldom, 
however,  discovered  until  labor  has  commenced,  and  even  if  it  be 
altered  the  child  is  extremely  apt  to  resume,  in  a  short  time,  the  faulty 
position  in  which  it  was  formerly  lying.  Still  there  can  be  no  harm 
in  making  the  attempt,  since  the  operation  itself  is  in  no  way  painful, 
and  is  absolutely  without  risk  either  to  the  mother  or  child.  When 

1  De  la  Version  par  Manoeuvres  externes.    Paris,  1878. 
31 


482  OBSTETRIC    OPERATIONS. 

the  transverse  presentation  is  detected  early  in  labor,  I  believe  it  is 
good  practice  to  endeavor  to  remedy  it  by  external  manipulation,  and, 
if  it  fails,  we  may  at  once  proceed  to  other  and  more  certain  methods  of 
operating.  The  procedure  itself  is  abundantly  simple.  The  patient 
is  placed  on  her  back,  and  the  position  of  the  foetus  ascertained  by 
palpation  as  accurately  as  possible,  in  the  manner  already  described. 
The  palms  of  the  hands  being  then  placed  over  the  opposite  poles  of 
the  foetus,  by  a  series  of  gentle  gliding  movements  the  head  is  pushed 
toward  the  'pelvic  brim,  while  the  breech  is  moved  in  the  opposite 
direction.  The  facility  with  which  the  fo3tus  may  sometimes  be  moved 
in  this  way  can  hardly  be  appreciated  by  those  who  have  never  at- 
tempted the  operation.  As  soon  as  the  change  is  effected,  the  long 
diameters  of  the  foetus  and  the  uterus  will  correspond,  and  vaginal 
examination  will  show  that  the  shoulder  is  no  longer  presenting  and 
that  the  head  is  over  the  pelvic  brim.  If  the  os  be  sufficiently  dilated, 
and  labor  in  progress,  the  membranes  should  now  be  punctured,  and 
the  position  of  the  foetus  maintained  for  a  short  time  by  external 
pressure  until  we  are  certain  that  the  cephalic  presentation  is  perma- 
nently established.  If  labor  be  not  in  progress,  an  attempt  may  at 
least  be  made  to  effect  the  same  object  by  pads  and  a  binder ;  one  pad 
being  placed  on  the  side  of  the  uterus  in  the  situation  of  the  breech, 
and  another  on  the  opposite  side  in  the  situation  of  the  head. 

On  account  of  the  difficulty  of  performing  cephalic  version  in  the 
manner  usually  recommended,  it  has  practically  scarcely  been  attempted, 
and,  with  the  exception  of  some  more  recent  authors,  it  is  generally 
condemned  by  writers  on  systematic  midwifery.  Still,  the  operation 
offers  unquestionable  advantages  in  those  transverse  presentations  in 
which  rapid  delivery  is  not  necessary,  and  in  which  the  only  object  of 
interference  is  the  rectification  of  malposition ;  for,  if  successful,  the 
child  is  spared  the  risk  of  being  drawn  footling  through  the  pelvis. 
The  objections  to  cephalic  version  are  based  entirely  on  the  difficulty 
of  performance ;  and,  undoubtedly,  to  introduce  the  hand  within  the 
uterus,  search  for,  seize,  and  afterward  place  the  slippery  head  in  the 
brim  of  the  pelvis,  could  not  be  an  easy  process,  even  under  the  most 
favorable  circumstances,  and  must  always  be  attended  with  consider- 
able risk  to  the  mother.  Velpeau,  who  strongly  advocated  the  oper- 
ation, was  of  opinion  that  it  might  be  more  easily  accomplished  by 
pushing  up  the  presenting  part,  than  by  seizing  and  bringing  down 
the  head.  Wigand  more  distinctly  pointed  out  that  the  head  could  be 
brought  to  a  proper  position  by  external  manipulation,  aided  by  the 
fingers  of  one  hand  within  the  vagina.  Braxton  Hicks  has  laid  down 
clear  rules  for  its  performance,  which  render  cephalic  version  easy  to 
accomplish  under  favorable  conditions,  and  will  doubtless  cause  it  to 
become  a  recognized  mode  of  treating  malpositions.  The  number  of 
cases,  however,  in  which  it  can  be  performed  must  always  be  limited, 
since,  as  in  turning  by  external  manipulation  alone,  it  is  necessary  that 
the  liquor  amnii  should  be  still  retained,  or  at  least  have  only  recently 
escaped ;  that  the  presentation  be  freely  movable  about  the  pelvic  brim ; 
and  that  there  be  no  necessity  for  rapid  delivery.  Dr.  Hicks  does  not 
believe  protrusion  of  the  arm  to  be  a  centra-indication,  and  advises 


TURNING.  483 

that  it  should  be  carefully  replaced  within  the  uterus.  When,  how- 
ever, protrusion  of  the  arm  has  occurred,  the  thorax  is  so  constantly 
pushed  down  into  the  pelvis  that  replacement  can  neither  be  safe  nor 
practicable,  except  under  unusually  favorable  conditions,  and  podalic 
version  will  be  necessary. 

Method  of  Performance. — It  is  impossible  to  describe  the  method 
of  performing  cephalic  version  more  concisely  and  clearly  than  in  Dr. 
Hicks's  own  words.  "  Introduce,"  he  says,  "  the  left  hand  into  the 
vagina,  as  in  podalic  version ;  place  the  right  hand  on  the  outside  of 
the  abdomen,  in  order  to  make  out  the  position  of  the  foetus  and  the 
direction  of  its  head  and  feet.  Should  the  shoulder,  for  instance,  pre- 
sent, then  push  it  with  one  or  two  fingers  in  the  direction  of  the  feet. 
At  the  same  time  pressure  with  the  other  hand  should  be  exerted  on 
the  cephalic  end  of  the  child.  This  will  bring  the  head  down  to  the 
os ;  then  let  the  head  be  received  on  the  tips  of  the  two  inside  fingers. 
The  head  will  play  like  a  ball  between  the  two  hands ;  it  will  be  under 
their  command,  and  can  be  placed  in  almost  any  part  at.  will.  Let  the 
head  then  be  placed  over  the  os,  taking  care  to  rectify  any  tendency  to 
face-presentation.  It  is  as  well,  if  the  breech  will  not  rise  to  the 
fundus  readily,  after  the  head  is  fairly  in  the  os,  to  withdraw  the  hand 
from  the  vagina,  and  with  it  press  up  the  breech  from  the  exterior. 
The  hand  which  is  retaining  gently  the  head  from  the  outside  should 
continue  there  for  some  little  time,  till  the  pains  have  insured  the 
retention  of  the  child  in  its  new  position  and  the  adaptation  of  the 
uterine  walls  to  its  new  form.  Should  the  membranes  be  perfect,  it  is 
advisable  to  rupture  them  as  soon  as  the  head  is  at  the  os  uteri;  during 
their  flow  and  after,  the  head  will  move  easily  into  its  proper  position." 

The  procedure  thus  described  is  so  simple,  and  would  occupy  so 
short  a  time,  that  there  can  be  no  objection  to  trying  it.  Should  we 
fail  in  our  endeavors,  we  shall  not  be  in  a  worse  position  for  effecting 
delivery  by  podalic  version,  which  can  be  proceeded  with  without 
removing  the  hand  from  the  vagina,  or  in  any  way  altering  the  posi- 
tion of  the  patient. 

The  method  of  performing  podalic  [or  bi-polar]  version  varies  with 
the  nature  of  each  particular  case.  In  describing  the  operation  it  has 
been  usual  to  divide  the  cases  into  those  in  which  the  circumstances 
are  favorable  and  the  necessary  manoeuvres  easily  accomplished,  and 
those  in  which  there  are  likely  to  be  considerable  difficulties  and 
increased  risk  to  the  mother.  This  division  is  eminently  practicable, 
since  nothing  can  be  more  variable  than  the  circumstances  under  which 
version  may  be  required.  Before  describing  the  steps  of  the  operation, 
it  may  be  well  to  consider  some  general  conditions  applicable  to  all 
cases  alike. 

In  England  the  ordinary  position  on  the  left  side  is  usually  em- 
ployed. On  the  Continent  and  in  America  the  patient  is  placed  on 
her  back,  with  the  legs  supported  by  assistants,  as  in  lithotomy.  The 
former  position  is  preferable,  not  only  as  a  matter  of  custom,  and  as 
involving  much  less  fuss  and  exposure  of  the  person,  but  because  it 
admits  of  both  the  operator's  hands  being  more  easily  used  in  concert. 
In  certain  difficult  cases,  when  the  liquor  amnii  has  escaped  and  the 


484  OBSTETRIC    OPERATIONS. 

back  of  the  child  is  turned  toward  the  spine  of  the  mother,  the  dorsal 
decubitus  presents  some  advantages  in  enabling  the  hand  to  pass  more 
readily  over  the  body  of  the  child  ;  but  such  cases  are  comparatively 
rare.  The  patient  should  be  brought  to  the  side  of  the  bed,  across 
which  she  should  be  laid,  with  the  hips  projecting  over  and  parallel 
to  the  edge,  the  knees  being  flexed  toward  the  abdomen,  and  separated 
from  each  other  by  a  pillow  or  by  an  assistant.  Means  should  be 
taken  to  restrain  the  patient  if  necessary,  and  prevent  her  involun- 
tarily starting  from  the  operator,  as  this  might  not  only  embarrass  his 
movements,  but  be  the  cause  of  serious  injury. 

The  exhibition  of  anaesthetics  is  peculiarly  advantageous.  There  is 
nothing  which  tends  to  facilitate  the  steps  of  the  process  so  much  as 
stillness  on  the  part  of  the  patient,  and  the  absence  of  strong  uterine 
contraction.  When  the  vagina  is  very  irritable  and  the  uterus  firmly 
contracted  around  the  body  of  the  child,  complete  anaesthesia  may 
enable  us  to  effect  version  when  without  it  we  should  certainly  fail. 

It  should  be.  remembered  that,  since  in  all  forms  of  version  much 
manipulation  is  necessary,  antiseptic  precautions  should  be  very  rigidly 
enforced. 

The  most  favorable  time  for  operating  is  when  the  os  is  fully  dilated, 
before,  or  immediately  after,  the  rupture  of  the  membranes  and  the 
discharge  of  the  liquor  amnii.  The  advantage  gained  by  operating 
before  the  waters  have  escaped  cannot  be  overstated,  since  we  can  then 
make  the  child  rotate  with  great  facility  in  the  fluid  medium  in  which 
it  floats.  In  the  ordinary  operation,  in  which  the  hand  is  passed  into 
the  uterus,  it  is  essential  to  wait  until  the  os  is  of  sufficient  size  to 
admit  of  its  being  introduced  with  safety.  This  may  generally  be 
done  when  the  os  is  the  size  of  a  crown-piece,  especially  if  it  be  soft 
and  yielding. 

The  practice  followed  with  regard  to  the  hand  to  be  used  in  turning 
varies  considerably.  Some  accoucheurs  always  employ  the  right  hand, 
others  the  left,  and  some  one  or  other  according  to  the  position  of  the 
child.  In  favor  of  the  right  hand,  it  is  said  that  most  practitioners 
have  more  power  with  it,  and  are  able  to  use  it  with  greater  gentleness 
and  delicacy.  In  transverse  presentations,  if  the  abdomen  of  the  child 
be  placed  anteriorly,  the  right  hand  is  said  to  be  the  proper  one  to  use, 
on  account  of  the  greater  facility  with  which  it  can  be  passed  over  the 
front  of  the  child ;  and  in  difficult  cases  of  this  kind  when  we  are 
operating  with  the  patient  on  her  back,  it  certainly  can  be  employed 
with  more  precision  than  the  left.  In  all  ordinary  cases,  however,  the 
left  hand  can  be  introduced  much  more  easily  in  the  axis  of  the  pass- 
ages, the  back  of  the  hand  adapts  itself  readily  to  the  curve  of  the 
sacrum,  and,  even  when  the  child's  abdomen  lies  anteriorly,  it  can  be 
passed  forward  without  difficulty  so  as  to  seize  the  feet.  These  advan- 
tages are  sufficient  to  recommend  its  use,  and  very  little  practice  is 
required  to  enable  the  practitioner  to  manipulate  with  it  as  freely  as 
with  the  right.  If,  in  addition,  we  remember  that  the  right  hand  is 
required  to  operate  on  the  foetus  through  the  abdominal  walls — and 
this  is  a  point  which  should  never  be  forgotten — we  shall  have  abun- 
dant reasons  for  laying  it  down  as  a  rule  that  the  left  hand  should 


TURNING. 


485 


generally  be  employed.  Before  passing  the  hand  and  arm  they  should 
be  freely  lubricated,  with  the  exception  of  the  palm,  which  is  left 
untouched  to  admit  a  firm  grasp  being  taken  of  the  foetal  limbs.  It 
is  also  advisable  to  remove  the  coat,  and  bare  the  arm  as  high  as  the 
elbow. 

As  it  should  be  a  cardinal  rule  to  resort  to  the  simplest  procedure 
when  practicable,  it  will  be  well  to  consider  first  the  method  by  com- 
bined external  and  internal  manipulation,  without  passing  the  hand 
into  the  uterus,  and  subsequently  that  which  involves  the  introduction 
of  the  hand. 


FIG.  160. 


First  stage  of  bi-polar  version.    Elevation  of  the  head  and  depression  of  the  breech. 

(After  BARNES.) 

Turning  by  Combined  External  and  Internal  Manipulation. — 
To  eifect  podalic  version  by  the  combined  method,  it  is  an  essential 
preliminary  to  ascertain  the  situation  of  the  foetus  as  accurately  as 
possible.  It  will  generally  be  easy,  in  transverse  presentations,  to 
make  out  the  breech  and  head  by  palpation  ;  while,  in  head  presenta- 
tions, the  fontanelles  will  show  to  which  side  of  the  pelvis  the  face  is 
turned.  The  left  hand  is  then  to  be  passed  carefully  into  the  vagina, 
in  the  axis  of  the  canal,  to  a  sufficient  extent  to  admit  of  the  fingers 
passing  freely  into  the  cervix.  To  eifect  this,  it  is  not  always  neces- 
sary to  insert  the  whole  hand,  three  or  four  fingers  being  generally 
sufficient. 

If  the  head  lie  in  the  first  (Q.L.A.)  or  fourth  (O.L.P.)  position,  push 
it  upward  and  to  the  left ;  while  the  other  hand,  placed  externally  on 


486 


OBSTETRIC    OPERATIONS, 


the  abdomen,  depresses  the  breech  toward  the  right  (Fig.  160).  By 
this  means  we  act  simultaneously  on  both  extremities  of  the  child's 
body,  and  easily  alter  its  position.  The  breech  is  pushed  down  gently 


FIG.  161. 


Second  stage  of  bi-polar  version.    Elevation  of  the  shoulders  and  depression  of  the  breech. 

(After  BAENES.) 

but  firmly,  by  gliding  the  hand  over  the  abdominal  wall.  The  head 
will  now  pass  out  of  reach,  and  the  shoulders  will  arrive  at  the  os 
and  will  lie  on  the  tips  of  the  fingers.  This  is  similarly  pushed 

FIG.  162. 


Third  stage  of  bi-polar  version.     Seizure  of  the  knee  and  partial  elevation  of  the  head. 

(After  BARNES.) 

upward  in  the  same  direction  as  the  head  (Fig.  161),  the  breech  at  the 
same  time  being  still  further  depressed,  until  the  knee  comes  within 
reach  of  the  fingers,  when  (the  membranes  being  now  ruptured,  if  still 


TURNING. 


487 


unbroken)  it  is  seized  and  pulled  down  through  the  os  (Fig.  162). 
Occasionally  the  foot  conies  immediately  over  the  os,  when  it  can  be 
seized  instead  of  the  knee.  Version  may  be  facilitated  by  changing 
the  position  of  the  external  hand,  and  pushing  the  head  upward  from 
the  iliac  fossa,  instead  of  continuing  the  attempt  to  depress  the  breech 
(Figs.  162  and  163).  These  manipulations  should  always  be  carried 
on  in  the  intervals,  and  desisted  from  when  the  pains  come  on ;  and 
when  the  pains  recur  with  great  force  and  frequency,  the  advantage  of 
chloroform  will  be  particularly  apparent.  In  the  second  (O.D.A.)  and 
third  (O.D.P.)  positions,  the  steps  of  the  operation  should  be  reversed ; 
the  head  is  pushed  upward  and  to  the  right,  the  breech  downward  and 
to  the  left.  When  the  position  cannot  be  made  out  with  certainty,  it 


FIG.  163. 


Fourth  stage  of  bi-polar  version. 


Drawing  down  of  the  legs  and  completion  of  version. 
(After  BARNES.) 


is  well  to  assume  that  it  is  the  first  (O.L.A.),  since  that  is  the  one  most 
frequently  met  with  ;  and  even  if  it  be  not,  no  great  inconvenience  is 
likely  to  occur.  If  the  os  be  not  sufficiently  open  to  admit  of  de- 
livery being  concluded,  the  lowrer  extremity  can  be  retained  in  its  new 
position  with  one  finger  until  dilatation  is  sufficiently  advanced  or 
until  the  uterus  has  permanently  adapted  itself  to  the  altered  position 
of  the  child,  either  of  which  results  will  generally  be  effected  in  a  short 
space  of  time. 

In  transverse  presentations  the  same  means  are  to  be  adopted,  the 
shoulder  being  pushed  upward  in  the  direction  of  the  head,  while 
the  breech  is  depressed  from  without.  This  is  frequently  sufficient 
to  bring  the  knees  within  reach  especially  if  the  membranes  are 


488  OBSTETRIC    OPERATIONS. 

entire,  but  version  is  much  facilitated  by  pressing  the  head  upward 
from  without,  alternately  with  depression  of  the  breech.  Jf  the  liquor 
ainuii  has  escaped  and  the  uterus  is  firmly  contracted  round  the  body 
of  the  child,  it  will  be  found  impossible  to  eifect  an  alteration  in  its 
position  without  the  introduction  of  the  hand,  and  the  ordinary 
method  of  turning  must  be  employed.  The  peculiar  advantage  of  the 
combined  process  is,  that  it  in  no  way  interferes  with  the  latter,  for, 
should  it  not  succeed,  the  hand  can  be  passed  on  into  the  uterus 
without  withdrawal  from  the  vagina  (provided  the  os  be  sufficiently 
dilated),  and  the  feet  or  knees  seized  and  brought  down. 

Turning  with  the  hand  introduced  into  the  uterus,  provided  the 
waters  have  not  or  have  only  recently  escaped  and  the  os  be  sufficiently 
dilated,  is  an  operation  generally  performed  with  ease. 

The  first  step,  and  one  of  the  most  important,  is  the  introduction  of 
the  hand  and  arm.  The  fingers  having  been  pressed  together  in  the 
form  of  a  cone,  the  thumb  lying  between  the  rest  of  the  fingers,  the 
hand,  thus  reduced  to  the  smallest  possible  dimensions,  is  slowly  and 
carefully  passed  into  the  vagina,  in  the  axis  of  the  outlet,  in  an  inter- 
val between  the  pains,  and  passed  onward  in  the  same  cautious  manner 
and  with  a  -semi-rotatory  motion  until  it  lies  entirely  within  the 
vagina,  the  direction  of  introduction  being  gradually  changed  from 
the  axis  of  the  outlet  to  that  of  the  brim.  If  uterine  contractions 
come  on,  the  hand  should  remain  passive  until  they  are  over.  It 
should  ever  be  borne  in  mind  as  one  of  the  fundamental  rules  in  per- 
forming version,  that  we  should  act  only  in  the  absence  of  pains,  and 
then  with  the  utmost  gentleness — all  force  and  violent  pushing  being 
avoided.  The  hand,  still  in  the  form  of  a  cone,  having  arrived  at  the 
os,  if  this  be  sufficiently  dilated,  may  be  passed  through  at  once.  If 
the  os  be  not  quite  open,  but  dilatable,  the  points  of  the  fingers  may 
be  gently  insinuated,  and  occasionally  expanded,  so  as  to  press  it  open 
sufficiently  to  permit  the  rest  of  the  hand  to  pass.  AVliile  this  is 
being  done  the  uterus  should  be  steadied  by  the  other  hand  placed 
externally,  or  by  an  assistant.  If  the  presentation  should  not  previ- 
ously have  been  made  out  with  accuracy,  we  can  now  ascertain  how 
to  pass  the  hand  onward,  so  that  its  palmar  surface  may  correspond 
with  the  abdomen  of  the  child. 

Rupture  of  the  Membranes. — The  membranes  should  now  be 
ruptured — if  possible  during  the  absence  of  pain,  so  as  to  prevent  the 
waters  being  forced  out.  The  hand  and  arm  form  a  most  efficient 
plug,  and  the  liquor  amnii  cannot  escape  in  any  quantity.  Some 
practitioners  recommend  that,  before  rupturing  the  membranes,  the 
hand  should  be  passed  onward  between  them  and  the  uterine  walls, 
until  we  reach  the  feet.  By  so  doing  we  run  the  risk  of  separating 
the  placenta ;  besides,  we  have  to  introduce  the  hand  much  farther 
than  may  be  necessary,  since  the  knees  are  often  found  lying  quite 
close  to  the  os.  As  soon  as  the  membranes  are  perforated,  the  hand 
can  be  passed  on  in  search  of  the  feet  (Fig.  164).  At  this  stage  of 
the  operation  increased  care  is  necessary  to  avoid  anything  like  force ; 
and  should  a  pain  come  on,  the  hand  must  be  kept  perfectly  flat  and 
still,  and  rather  pressed  on  the  body  of  the  child  than  on  the  uterus. 


TURNING. 


489 


If  the  pains  be  strong,  much  inconvenience  may  be  felt  from  the  com- 
pression ;  and  were  the  onward  movement  continued,  or  the  hand  even 
kept  bent  in  the  conical  form  in  which  it  was  introduced,  rupture  of 
the  uterine  walls  might  easily  be  caused.  This  is  not  likely  to  occur 
in  the  class  of  cases  now  under  consideration,  for  it  is  chiefly  when 
the  waters  have  long  escaped  that  the  progress  of  the  hand  is  a  matter 
of  difficulty.  Valuable  assistance  may  now  be  given  by  pressing  the 
breech  downward  from  without,  so  as  to  bring  the  knees  or  feet  more 
easily  within  the  reach  of  the  internal  hand.  Having  arrived  at  the 
knees  or  feet,  they  may  be  seized  between  the  fingers  and  drawn 


FIG.  164. 


Seizure  of  the  feet  when  the  hand  is  introduced  into  the  uterus. 

downward  in  the  absence  of  a  pain  (Fig.  165).  This  will  cause  the 
Io3tus  to  revolve  on  its  axis,  the  breech  will  descend,  and  at  the  same 
time  the  ascent  of  the  head  may  be  assisted  by  the  right  hand  from 
without.  It  is  a  question  with  many  accoucheurs  which  part  of  the 
inferior  extremities  should  be  seized  and  brought  down.  Some  recom- 
mend us  to  seize  both  feet,  others  prefer  one  only,  while  some  advise 
the  seizure  of  one  or  both  knees.  In  a  simple  case  of  turning,  before 
the  escape  of  the  waters,  it  does  not  matter  much  which  of  these  plans 
is  followed,  since  version  is  accomplished  with  the  greatest  ease  by 
any  one  of  them.  The  seizure  of  the  knee,  however,  instead  of  the  feet, 
offers  certain  advantages  which  should  not  be  overlooked.  It  is  gener- 
ally more  accessible,  affords  a  better  hold  (the  fingers  being  inserted  in 


490 


OBSTETRIC    OPERATIONS. 


the  flexure  of  the  ham),  and,  being  nearer  the  spine,  traction  acts  more 
directly  on  the  body  of  the  child.  Any  danger  of  mistaking  the  knee 
for  the  elbow  may  be  obviated  by  remembering  the  simple  rule  that 
the  salient  angle  of  the  former,  when  the  thigh  is  flexed,  looks  toward 
the  head  of  the  child,  of  the  latter  toward  its  feet.  Certain  advantages 
may  also  be  gained  by  bringing  down  one  foot  or  knee  only,  instead  of 
both.  When  one  inferior  extremity  remains  flexed  on  the  body  of  the 
child,  the  part  which  has  to  pass  through  the  os  is  larger  than  when 
both  legs  are  drawn  down,  and  consequently  the  os  is  more  perfectly 
dilated,  and  less  difficulty  is  likely  to  be  experienced  in  the  delivery 


FIG.  165. 


Drawing  down  of  the  feet  and  completion  of  version. 

of  the  rest  of  the  body,  so  that  the  risk  to  the  child  is  materially 
diminished. 

Simpson,  whose  views  have  been  adopted  by  Barnes  and  other 
writers,  recommends  the  seizing,  if  possible,  in  arm  presentations,  of 
the  knee  farthest  from  and  opposite  to  the  presenting  arm,  as  by  this 
means  the  body  is  turned  round  on  its  longitudinal  axis,  and  the  present- 
ing arm  and  shoulder  more  easily  withdrawn  from  the  os.  Dr.  Galabin 
has  carefully  investigated  this  point  in  a  recent  paper,1  and  contends 
that  there  is  a  greater  mechanical  advantage  in  seizing  the  leg  which 

i  Obst.  Trans,  for  1877,  vol.  xix.  p.  239. 


TUKNING. 


491 


is  nearest  to,  and  on  the  same  side  as,  the  presenting  arm,  and  this, 
moreover,  is  generally  more  readily  done. 

As  soon  as  the  head  has  reached  the  fundus,  and  the  lower  extremity 
is  brought  through  the  os,  the  case  is  converted  into  a  foot  or  knee 
presentation,  and  it  conies  to  be  a  question  whether  delivery  should 
now  be  left  to  Nature  or  terminated  by  art.  This  must  depend  to  a 
certain  extent  on  the  case  itself,  and  on  the  cause  which  necessitated 
version,  but,  generally,  it  will  be  advisable  to  finish  delivery  without 
unnecessary  delay.  To  accomplish  this,  downward  traction  is  made 
during  the  pains,  and  desisted  from  in  the  intervals  (Fig.  166).  As 


FIG.  166. 


Showing  the  completion  of  version.    (After  BARNES.) 

the  umbilical  cord  appears,  a  loop  should  be  drawn  down  ;  and  if  the 
hands  be  above  the  head,  they  must  be  disengaged  and  brought  over 
the  face,  in  the  same  manner  as  in  an  ordinary  footling  presentation. 
The  management  of  the  head,  after  it  descends  into  the  cavity  of  the 
pelvis,  must  also  be  conducted  as  in  labors  of  that  description. 

Turning  in  Placenta  Praevia. — In  cases  of  placenta  prjevia  the 
os  will,  as  a  rule,  be  more  easily  dilatable  than  in  transverse  pres- 
entations. Hicks's  method  offers  the  great  advantage  of  enabling  us 
to  perform  version  much  sooner  than  was  formerly  possible,  since  it 
only  requires  the  introduction  of  one  or  two  fingers  into  the  os  uteri. 
Should  we  not  succeed  by  it,  and  the  state  of  the  patient  indicates  that 
delivery  is  necessary,  we  have  at  our  command,  in  the  fluid  dilators,  a 


492 


OBSTETRIC    OPERATIONS. 


means  of  artificially  dilating  the  os  uteri  which  can  be  employed  with 
ease  and  safety.  If  we  have  to  do  with  a  case  of  entire  placental 
presentation,  *  the  hand  should  be  passed  at  that  point  where  the 
placenta  seems  to  be  least  attached.  This  will  always  be  better  than 
attempting  to  perforate  its  substance,  a  measure  sometimes  recom- 
mended, but  more  easily  performed  in  theory  than  in  practice.  If  the 
placenta  only  partially  presents,  the  hand  should,  of  course,  be  inserted 
at  its  free  border.  It  will  frequently  be  advisable  not  to  hasten 
delivery  after  the  feet  have  been  brought  through  the  os,  for  they  form 
of  themselves  a  very  efficient  plug,  and  effectually  prevent  further 
loss  of  blood ;  while,  if  the  patient  be  much  exhausted,  she  may  have 
her  strength  recruited  by  stimulants,  etc.,  before  the  completion  of 
delivery.  . 

FIG.  167. 


Showing  the  use  of  the  right  hand  in  abdomino-anterior  position. 

Turning-  in  Abdomino-anterior  Positions. — In  abdomino-ante- 
rior positions,  in  which  the  waters  have  escaped,  and  in  which,  there- 
fore, some  difficulty  may  be  reasonably  anticipated,  the  operation  is 
generally  more  easily  performed  with  the  patient  on  her  back ;  the 
right  hand  is  then  introduced  into  the  uterus,  and  the  left  employed 
externally  (Fig.  167).  In  this  way  the  internal  hand  has  to  be  passed 
a  shorter  distance  and  in  a  less  constrained  position.  The  operator 
then  sits  in  front  of  the  patient,  who  is  supported  at  the  edge  of  the 
bed  in  the  lithotomy  position  with  the  thighs  separated,  and  the  right 
hand  is  passed  up  behind  the  pubes  and  over  the  abdomen  of  the 
child. 

Difficult  Cases  of  Arm  Presentation. — The  difficulties  of  turn- 
ing culminate  in  those  unfavorable  cases  of  arm  presentation  in  which 
the  membranes  have  been  long  ruptured,  the  shoulder  and  arm  pressed 


TURNING.  493 

down  into  the  pelvis,  and  the  uterus  contracted  around  the  body  of 
the  child.  The  uterus  being  firmly  and  spasmodically  contracted,  the 
attempt  to  introduce  the  hand  often  only  makes  matters  worse,  by  in- 
ducing more  frequent  and  stronger  pains.  Even  if  the  hand  and  arm 
be  successfully  passed,  much  difficulty  is  often  experienced  in  causing 
the  body  of  the  child  to  rotate;  for  we  have  no  longer  the  fluid 
-  medium  present  in  which  it  floated  and  moved  with  ease,  and  the  arm 
of  the  operator  may  be  so  cramped  and  pained  by  the  pressure  of 
the  uterine  walls  as  to  be  rendered  almost  powerless.  The  risk  of 
laceration  is  also  greatly  increased,  and  the  care  necessary  to  avoid  so 
serious  an  accident  adds  much  to  the  difficulty  of  the  operation. 

Value  of  Anaesthesia  in  Relaxing  the  Uterus. — In  these  per- 
plexing cases  various  expedients  have  been  tried  to  cause  relaxation  of 
the  spasmodically  contracted  uterine  fibres,  such  as  copious  venesection 
in  the  erect  attitude  until  fainting  is  induced,  warm  baths,  tartar  emetic, 
and  .similar  depressing  agents.  None  of  these,  however,  is  so  useful 
as  the  free  administration  of  chloroform,  which  has  practically  super- 
seded them  all,  and  often  answers  most  effectually  when  given  to  its 
full  surgical  extent. 

The  hand  must  be  introduced  with  the  precautions  already  described. 
If  the  arm  be  completely  protruded  into  the  vagina,  we  should  pass 
the  hand  along  it  as  a  guide,  and  its  palmar  surface  will  at  once  indi- 
cate the  position  of  the  child's  abdomen.  No  advantage  is  gained  by 
amputation,  as  is  sometimes  recommended.  When  the  os  is  reached, 
the  real  difficulties  of  the  operation  commence,  and,  if  the  shoulder  be 
firmly  pressed  down  into  the  brim  of  the  pelvis,  it  may  not  be  easy  to 
insinuate  the  hand  past  it.  It  is  allowable  to  repress  the  presenting 
part  a  little,  but  with  extreme  caution,  for  fear  of  injuring  the  con- 
tracted uterine  parietes.  Herman1  has  pointed  out  that  in  some  cases 
the  difficulty  is  increased  by  the  shoulder  of  the  prolapsed  arm  being 
caught  beneath  the  contraction  ring  (Bandl's),  and  he  advises  that  it 
should  be  released  by  pressing  it  toward  the  centre  of  the  cervical 
canal.  It  is  better  to  insinuate  the  hand  past  the  obstruction,  which 
can  generally  be  done  by  patient  and  cautious  endeavors.  Having 
succeeded  in  passing  the  shoulder,  the  hand  is  to  be  pressed  forward 
in  the  intervals,  being  kept  perfectly  flat  and  still  on  the  body  of  the 
foetus  when  the  pains  come  on.  It  is  much  safer  to  press  on  it  than 
on  the  uterine  walls,  which  might  readily  be  lacerated  by  the  projecting 
knuckles.  When  the  hand  has  advanced  sufficiently  far,  it  will  be 
better,  for  the  reasons  already  mentioned,  to  seize  and  bring  down  one 
knee  only. 

When  the  Foot  is  Brought  Down  but  the  Foetus  will  not 
Revolve. — Even  when  the  foot  has  been  seized  and  brought  through 
the  os,  it  is  by  no  means  always  easy  to  make  the  child  revolve  on  its 
axis,  as  the  shoulder  is  often  so  firmly  fixed  in  the  pelvic  brim  as  not 
to  rise  toward  the  fundus.  Some  assistance  may  be  derived  from 
pushing  the  head  upward  from  without,  which,  of  course,  would  raise 
the  shoulder  along  with  it.  If  this  should  fail,  we  may  effect  our 

1  "  Note  on  One  of  the  Causes  of  Difficulty  in  Turning,"  Obst.  Trans,  for  1886,  vol.  xxviii.  p.  150. 


494  OBSTETRIC    OPERATIONS. 

object  by  passing  a  noose  of  tape  or  wire  ribbon  around  the  limb,  by 
'which  traction  is  made  downward  and  backward ;  at  the  same  time 
the  other  hand  is  passed  into  the  vagina  to  displace  the  shoulder  and 
push  it  out  of  the  brim.  It  is  evident  that  this  cannot  be  done  as  long 
as  the  limb  is  held  by  the  left  hand,  as  there  is  no  room  for  both  hands 
to  pass  into  the  vagina  at  the  same  time.  By  this  manoeuvre  version 
may  be  often  completed  when  the  foetus  cannot  be  turned  in  the 
ordinary  way.  Various  instruments  have  been  invented  both  for 
passing  a  fillet  around  the  child's  limb  and  for  repressing  the  shoulder, 
but  none  of  them  can  compete,  either  in  facility  of  use  or  safety,  with 
the  hand  of  the  accoucheur. 

Mutilation  of  the  Foetus. — Should  all  attempts  at  version  fail,  no 
resource  is  left  but  the  mutilation  of  the  child,  either  by  evisceration 
or  decapitation.  This  extreme  measure  is,  fortunately,  seldom  neces- 
sary, as  with  due  care  version  may  generally  be  effected,  even  under 
the  most  unfavorable  circumstances.1 


CHAPTER    III. 

THE  FORCEPS. 

Use  of  the  Forceps  in  Modern  Practice. — Of  all  obstetric  opera- 
tions the  most  important,  because  the  most  truly  conservative  both  to 
the  mother  and  child,  is  the  application  of  the  forceps.  In  modern 
midwifery  the  use  of  the  instrument  is  much  extended,  and  it  is  now 
applied  by  some  of  our  most  experienced  accoucheurs  with  a  frequency 
which  older  practitioners  would  have  strongly  reprobated.  That  the 
injudicious  and  unskilful  use  of  the  forceps  is  capable  of  doing  much 
harm,  no  one  will  for  a  moment  deny.  This,  however,  is  not  a  reason 
for  rejecting  the  recommendation  of  those  who  advise  a  more  frequent 
resort  to  the  operation,  but  rather  for  urging  on  the  practitioner  the 
necessity  of  carefully  studying  the  manner  of  performing  it,  and  of 
making  himself  familiar  with  the  cases  in  which  it  is  easy  or  the 
reverse.  Nothing  but  practice — at  first  on  the  dummy,  and  afterward 
in  actual  cases — can  impart  the  operative  dexterity  which  it  should  be 
the  aim  of  every  obstetrician  to  acquire,  and  without  which  there  can 
be  no  assurance  of  his  doing  his  duty  to  his  patient  efficiently. 

Description. — The  forceps  may  best  be  described  as  a  pair  of  arti- 
ficial hands  by  which  the  fcetal  head  may  be  grasped  and  drawn  through 
the  maternal  passages  by  vis  a  fronte,  when  the  vis  a  tergo  is  deficient. 
This  description  will  impress  on  the  mind  the  important  action  of  the 
instrument  as  a  tractor,  to  which  all  its  other  powers  are  subservient* 

1  See  note,  p.  536. 


THE    FORCEPS. 


495 


The  forceps  consists  of  two  separate  blades  of  a  curved  form,  adapted 
to  fit  the  child's  head ;  a  lock  by  which  the  blades  are  united  after 
introduction ;  and  handles  which  are  grasped  by  the  operator,  and  by 
means  of  which  traction  is  made.  It  would  be  a  wearisome  and  un- 
satisfactory task  to  dwell  on  all  the  modifications  of  the  instrument 
which  have  been  made,  which  are  so  numerous  as  to  make  it  almost 
appear  as  if  no  one  could  practise  midwifery  with  the  least  pretension 
to  eminence,  unless  he  has  attached  his  name  to  a  new  variety  of 
forceps.  *' 

The  Short  Forceps. — The  original  instrument,  invented  by  the 
Chaniberlens,  may  be  looked  upon  as  the  type  of  the  short  straight 
forceps,  which  has  been  more  employed  than  any  others  and  which, 
perhaps,  finds  its  best  representative  in  the  short  forceps  of  Denman 
(Fig.  168).  Indeed,  the  only  essential  difference  between  the  two  is 

FIG.  168. 


Denman's  short  forceps. 

the  lock  of  the  latter,  originally  invented  by  Smellie,  which  is  so 
excellent  that  it  has  been  adopted  in  all  British  forceps ;  and  which, 
for  facility  of  juncture,  is  much  superior  to  either  the  French  pivot  or 
the  German  lock,  while  for  firmness  it  is,  for  all  practical  purposes,  as 
good  as  either.  In  this  instrument  the  blades  are  seven  and  the  handle 
four  and  three-eighths  inches  in  length  ;  the  extremities  of  the  blades 
are  exactly  one  inch  apart,  and  the  space  between  them  at  their  widest 
part  is  two  and  seven-eighths  inches.  The  blades  measure  one  and 
three-fourths  inches  at  their  greatest  breadth  and  spring  with  a  regular 


496 


OBSTETRIC    OPERATIONS. 


sweep  directly  from  the  lock,  there  being  no  shank.  The  blades  are 
formed  of  the  best  and  most  highly  tempered  steel,  to  resist  the  strain 
to  which  they  are  occasionally  subjected,  and  they  are  smooth  and 
rounded  on  their  inner  surface,  to  obviate  the  risk  of  injury  to  the 
scalp  of  the  child. 

The  special  advantage  claimed  for  this  form  of  instrument  is  that, 
the  two  halves  being  precisely  similar,  no  care  or  forethought  is 
required  on  the  part  of  the  practitioner  as  to  wrhich  blade  should  be 
introduced  uppermost — an  advantage  of  no  great  value,  since  no  one 
should  undertake  a  case  of  forceps  delivery  who  has  not  sufficient 
knowledge  of  the  operation,  and  presence  of  mind  enough,  to  obviate 
any  risk  from  the  introduction  of  the  wrong  blade  first.  On  account 
of  its  shortness,  and  the  want  of  the  second  or  pelvic  curve,  it  is  only 
adapted  for  cases  in  which  the  head  is  low  down  in  the  pelvis,  or 
actually  resting  on  the  perineum. 

The  Pelvic  Curve. — The  question  of  the  second  or  pelvic  curve  is 
one  on  which  there  is  much  difference  of  opinion.  The  forceps  we  are 
now  considering,  and  the  many  modifications  formed  on  the  same  plan, 
is  constructed  solely  with  reference  to  its  grasp  on  the  child's  head, 
and  without  regard  to  the  axes  of  the  maternal  passages.  Conse- 
quently, were  we  to  introduce  it  when  the  head  was  at  the  upper  part 
of  the  pelvis,  we  could  not  fail  to  expose  the  soft  parts  to  the  risk  of 
contusion,  and  (in  consequence  of  the  necessity  of  drawing  more  directly 
backward)  unduly  stretch  and  even  lacerate  the  perineum.  Hence  it 
is  now  admitted  by  obstetricians,  with  few  exceptions,  that  the  second 
curve  is  essential  before  the  complete  descent  of  the  head,  although  it 
is  not  absolutely  so  after  this  has  taken  place.  The  only  circumstances 
under  which  a  straight  blade  can  possess  any  superiority  are  in  certain 
cases  of  occipito-posterior  position,  in  which  it  is  found  necessary  to 
rotate  the  head  around  a  large  extent  of  the  pelvis, 
when  the  circular  sweep  of  a  strongly  curved  instru- 
ment might  prove  injurious.  Such  cases,  however, 
are  of  rare  occurrence,  and  need  in  no  way  influ- 
ence the  general  employment  of  the  pelvic  curve. 

Zeigler's  Forceps. — The  short  forceps  usually 
employed  in  Scotland  is  the  invention  of  the  late 
Dr.  Zeigler(Fig.  169),  and  is  useful  from  the  facility 
with  which  the  blades  may  be  introduced  in  accurate 
apposition  to  each  other,  a  point  which  in  practice  is 
of  no  little  value.  In  general  size  and  appearance  it 
closely  resembles  Denman's  forceps,  but  the  fenestra 
of  the  lower  blade  is  continued  down  to  the  handle. 
In  introducing,  the  lower  blade  is  slipped  over  the 
handle  of  the  other  blade  already  in  situ,  and  thus 
it  is  guided  with  great  certainty  into  a  proper 
position,  locking  itself  as  it  passes  on.  This  in- 
strument has  the  disadvantage  of  not  having 
the  second  curve,  but  the  facility  of  introduction 
has  rendered  it  a  great  favorite  with  many  who  have  been  in  the 
habit  of  employing  it. 


FIG.  169. 


Zeigler's  forceps. 


THE    FORCEPS. 


497 


The  Long  Forceps. — For  cases  in  which  the  head  is  not  on  the 
perineum,  or  at  least  not  quite  low  in  the  pelvis,  a  longer  instrument 
is  essential.  To  meet  this  indication  Smellie  invented  the  long 
forceps,  which,  like  the  shorter  instrument,  has  been  very  variously 
modified.  The  most  perfect  instrument  of  the  kind  employed  in 
Great  Britain  is  that  known  as  Simpson's  forceps  (Fig.  170),  which 
combines  many  excellent  points  selected  from  the  forceps  of  various 
obstetricians,  as  well  as  some  original  additions,  and  which,  as  a  whole, 
was  never  surpassed,  until  Tarnier's  or  its  modification  was  invented. 


FIG.  170. 


e 


Simpson's  forceps. 

The  curved  portions  of  the  blades  are  six  and  one-quarter  inches 
long,  the  fenestra  measuring  one  and  one-quarter  inches  in  its  widest 
part.  The  extremities  of  the  blades  are  one  inch  asunder  when 
the  handles  are  closed,  and  three  inches  at  their  widest  part.  The 
object  of  this  somewhat  unusual  width  is  to  lessen  the  compressing 
power  of  the  instrument,  without  in  any  way  interfering  with  its  action 
as  a  tractor.  The  pelvic  curve  is  less  than  in  most  long  forceps,  so  as 
to  admit  of  the  rotation  of  the  head  when  necessary,  without  the  risk 
of  injuring  the  maternal  structures.  Between  the  curve  of  the  blade 
and  the  lock  is  a  straight  portion  or  shank,  measuring  two  and  three- 
eighths  inches,  wrhich,  before  joining  the  handle,  is  bent  at  right  angles 
into  a  knee.  This  shank  is  a  useful  addition  to  all  forceps,  and  is 

32 


498  OBSTETRIC    OPERATIONS. 

essential  in  the  long  forceps  to  insure  the  junction  of  the  blades  beyond 
the  parts  of  the  mother,  which  might  otherwise  be  caught  in  the  lock 
and  injured.  The  knees  serve  the  purpose  of  preventing  the  blades 
from  slipping  from  each  other  after  they  have  been  united.  They  also 
admit  of  one  finger  being  introduced  above  the  lock,  and  used  as  an 
aid  in  traction ;  a  provision  which  is  made  in  some  other  varieties  of 
long  forceps  by  a  semicircular  bend  in  each  shank.  The  handles, 
which  in  most  British  forceps  are  too  small  and  smooth  to  afford  a  firm 
grasp,  are  serrated  at  the  edge,  and  flattened  from  before  backward,  so 
as  to  fit  the  closed  fist  more  accurately.  At  their  extremities,  near  the 
lock,  there  are  a  pair  of  projecting  rests,  over  which  the  fore  and 
middle  fingers  may  be  passed  in  traction,  and  which  greatly  increase 
our  power  over  the  instrument.  Although  this  and  other  varieties  of 
the  long  forceps  are  specially  constructed  for  application  when  the 
head  is  high  in  the  pelvis,  it  answers  quite  as  well  as  the  short  forceps 
— indeed,  in  most  respects,  better — when  the  head  has  descended  low 
down.  It  is  a  decided  advantage  for  the  practitioner  to  habituate  him- 
.self  to  the  use  of  one  instrument,  with  the  application  and  power  of 
which  he  becomes  thoroughly  familiar.  It  is  a  mere  waste  of  space 
and  money  for  him  to  encumber  himself  with  a  number  of  instruments 
of  various  shapes  and  sizes,  and  he  may  be  sure  that  a  good  pair  of 
long  forceps  will  be  suitable  for  every  emergency,  and  in  any  position 
of  the  head. 

The  chief  argument  against  the  use  of  such  an  instrument  in  simple 
cases  is  its  great  power.  This,  however,  is  entirely  based  on  a  mis- 
conception. The  existence  of  power  does  not  involve  its  use,  and  the 
stronger  instrument  can  be  employed  with  quite  as  much  delicacy  and 
gentleness  as  the  weaker.  The  remarks  of  Dr.  Hodge1  on  this  point 
are  extremely  apposite,  and  are  well  worthy  of  quotation.  He  says  : 
"  Certainly  no  man  ought  to  apply  the  forceps  who  has  not  sufficient 
discretion  to  use  no  more  force  than  is  absolutely  requisite  for  safe 
delivery.  If,  therefore,  there  is  more  power  at  command,  he  is  not 
obliged  to  use  it ;  while,  on  the  contrary,  if  much  power  be  demanded, 
he  can,  within  the  bounds  of  prudence,  exercise  it  by  the  long  forceps, 
but  with  the  short  forceps  his  efforts  might  be  unavailing.  Moreover, 
in  cases  of  difficulty,  the  short  forceps  being  used,  the  practitioner 
would  be  forced  to  make  great  muscular  efforts ;  while  with  the  long 
forceps,  owring  to  the  great  leverage,  such  effort  will  be  comparatively 
trifling,  and,  of  course,  the  whole  force  demanded  can  be  much  more 
delicately,  and  at  the  same  time  efficiently,  applied,  and  with  more 
safety  to  the  tissues  of  the  child  and  its  parent." 

Continental  Forceps. — The  forceps  usually  employed  on  the  Con- 
tinent and  in  America  differs  considerably,  both  in  appearance  and 
construction,  from  those  in  use  in  England.  As  a  rule  it  is  a  larger 
and  more  powerful  instrument,  joined  by  a  pivot  or  button -joint,  and 
it  always  possesses  the  second  or  pelvic  curve.  Of  late  years  Simpson's 
forceps  has  been  much  employed  in  some  parts  of  Germany.  The 
chief  objection  to  the  Continental  instruments  is  their  cunibrousness. 

1  System  of  Obstetrics,  p.  242. 


THE    FORCEPS. 


499 


This  is  chiefly  in  the  handles,  which  in  many  of  them  are  forged  in  a 
piece  with  the  blades,  the  part  introduced  within  the  maternal  struc- 
tures not  being  materially  different  from  the  corresponding  part  of  the 
English  instrument. 

Tarnier's  Forceps. — The  forceps  invented  by  Professor  Tarnier 
(Fig.  171)  has  attracted  considerable  attention,  and  is  highly  esteemed 
by  all  who  have  used  it.  In  this  instrument  traction  is  not  made  on 
the  handles  by  which  the  blades  are  introduced  as  in  ordinary  forceps, 
but  on  a  supplementary  handle  (a)  subsequently  attached  to  the  blades 
near  the  lower  opening  of  their  fenestrse  (6).  The  advantage  claimed 
for  this  arrangement  is  that  less  force  is  required  in  traction,  which  can 


FIG.  171. 


FIG.  172. 


Tarnier's  forceps.  ['] 


Simpson's  axis-traction  forceps. 
c,6.  Traction  handle.    c,J.  Line  of  traction. 


always  be  made  in  the  proper  axis  of  the  pelvis ;  that  the  blades  are 
not  likely  to  slip;  and  that  rotation  of  the  head  is  not  interfered 
with.  The  handles  of  the  forceps,  moreover,  guide  the  operator  to  the 
direction  in  which  he  ought  to  pull,  since  all  that  is  required  is  to 
keep  the  traction  rods  parallel  to  them.  This  instrument,  however, 
although  theoretically  excellent,  is  somewhat  too  complicated  for 
general  use. 

Simpson's  Axis-traction  Forceps. — Prof.  A.  R.  Simpson,  of 
Edinburgh,  has  invented  a  modification  of  Tarnier's  instrument,  which 
he  calls  the  "Axis-traction  Forceps"  (Fig.  172).  The  supplementary 
handles  are  fixed  to  the  blades,  and  the  whole  mechanism  is  much 
simpler  than  in  Tarnier's  forceps.  Dr.  Simpson  reports  very  favorably 
of  this  forceps,  and  it  is  certainly  well  adapted  for  the  object  aimed  at. 


[i  The  original  Tarnier  forceps  had  blades  somewhat  like  those  of  Davis,  and  was  much  better 
than  his  present  style,  in  the  estimation  of  many  accoucheurs.— ED.] 


500  OBSTETRIC    OPERATIONS. 

For  some  years  I  have  used  it  to  the  exclusion  of  every  other  form, 
and  have  every  reason  to  be  satisfied  with  it,  especially  in  the  high 
forceps  operation,  in  which  it  seems  to  me  superior  to  any  other  instru- 
ment. Indeed,  the  facility  with  which  it  effects  delivery  in  such  cases 
is  often  very  striking;. 

Action  of  the  Instrument. — The  forceps  is  generally  said  to  act  in 
three  different  ways : 

First.  As  a  tractor. 
Second.  As  a  lever. 
Third.  As  a  compressor. 

It  is  more  especially  as  a  tractor  that  the  instrument  is  of  value,  and 
it  is  used  with  the  greatest  advantage  when  it  is  employed  merely  to 
supplement  the  action  of  the  uterus  which  is  insufficient  of  itself  to 
effect  delivery,  or  when,  from  some  complication,  it  is  necessary  to 
complete  labor  with  greater  rapidity  than  can  be  accomplished  by  the 
unaided  powers  of  Nature.  In  most  cases  traction  alone  is  sufficient ; 
but  in  order  that  it  may  act  satisfactorily,  and  that  the  instrument  may 
not  slip,  a  proper  construction  of  the  forceps,  and  a  sufficient  curvature 
of  the  blades,  are  essential.  The  want  of  these  is  the  radical  fault  of 
many  of  the  short,  straight  instruments  in  common  use,  which  have  a 
tendency  to  slip  during  our  efforts  at  extraction. 

The  forceps  acts  also  as  a  lever,  but  this  action  has  been  greatly  ex- 
aggerated. It  is  generally  described  as  a  lever  of  the  first  class,  the 
power  being  at  the  handles,  the  fulcrum  at  the  lock,  and  the  weight  at 
the  extremities.  There  may  possibly  be  some  leverage  power  of  this 
kind  when  the  instrument  is  first  introduced,  and  the  handles  held  so 
loosely  that  one  blade  is  able  to  work  on  the  other.  But,  as  ordinarily 
used,  the  handles  are  held  with  a  sufficiently  firm  grasp  to  prevent  this 
movement,  and  then  the  two  blades  practically  form  a  single  instru- 
ment. 

Galabin,  who  has  studied  this  subject  in  detail,  points  out1  that : 
"  1 .  The  lever  is  formed  by  both  blades  of  the  forceps  and  the  fcetal 
head  united  in  one  immovable  mass.  As  soon  as  the  blades  begin  to 
slip  over  the  head,  the  lever  is  decomposed,  and  the  swaying  movement 
ceases  to  have  any  mechanical  advantage.  2.  The  power  is  applied  to 
the  handles  in  a  slanting  direction.  The  resistance  or  weight  does  not 
act  at  a  point  either  between  the  former  and  the  fulcrum,  or  beyond 
the  fulcrum,  but  at  a  point  in  a  plane  nearly  at  right  angles  to  the  line 
joining  these  two  points,  and  its  direction  is  a  line  perpendicular  to 
that  plane  of  the  pelvis  in  which  the  greatest  section  of  the  head  is 
engaged ;  that  is  to  say,  in  the  case  of  straight  forceps,  nearly  parallel 
to  the  handles.  The  lever  formed  does  not,  therefore,  strictly  speak- 
ing, belong  to  any  one  of  the  three  orders  into  which  levers  are  com- 
monly divided.  3.  The  fulcrum  is  fixed  partly  by  friction,  partly  by 
the  combination  of  traction  with  oscillatory  movements — in  other 
words,  by  the  power  being  directed  in  great  measure  downward,  and 
only  slightly  to  one  side." 

He  further  shows  that  the  pendulum  motion  of  the  forceps  is  super- 

1  Galabin :  "  Action  of  Midwifery  Forceps  as  a  Lever,"  Obst.  Journ.,  1876-77,  vol.  iv.  p.  508. 


THE    FORCEPS.  501 

fluous  in  all  ordinary  forceps  operations,  in  which  traction  alone  is 
amply  sufficient  for  delivery  ;  but  that  when  the  head  is  impacted,  and 
great  force  is  required  for  its  extraction,  a  mechanical  advantage  may 
be  gained  from  having  recourse  to  an  oscillatory  movement,  which 
should,  however,  be  very  limited,  and  only  continued  if  found  to  effect 
distinct  advance  of  the  head. 

Regarding  the  compressive  power  of  the  instrument  there  has  been 
much  difference  of  opinion.  There  is  no  doubt  that  the  forceps,  espe- 
cially some  of  the  foreign  instruments  in  which  the  points  nearly 
approach  each  other,  is  capable  of  exerting  considerable  compression 
on  the  head.  It  is,  however,  extremely  problematical 'if  this  action  be 
of  real  value.  It  is  to  be  borne  in  mind  that  in  cases  of  protracted 
labor  the  head  has  been  already  moulded  and  compressed,  and  the 
bones  have  been  made  to  overlap  each  other  to  their  utmost  extent,  by 
the  sides  of  the  pelvis.  We  can  scarcely,  therefore,  expect  to  diminish 
the  head  much  more  by  the  forceps  without  employing  an  amount  of 
force  that  will  seriously  endanger  the  life  of  the  child.  It  is  in  cases 
of  disproportion  between  the  head  and  the  pelvis,  depending  on  slight 
antero-posterior  contraction  of  the  pelvic  brim,  that  diminution  of  the 
child's  head  by  compression  would  be  most  useful.  Then,  however, 
the  pressure  of  the  forceps  is  exerted  on  that  portion  of  the  head  which 
lies  in  the  most  roomy  diameter  of  the  pelvis,  where  there  is  no  want 
of  space.  If  this  pressure  does  not  increase  the  opposite  diameter,  which 
is  in  apposition  to  the  narrower  portion  of  the  pelvis,  it  can  at  least 
do  nothing  toward  lessening  it,  and  diminution  of  any  other  part  of 
the  child's  head  is  not  required. 

Dynamical  Action  of  the  Forceps. — The  mere  introduction  of 
the  forceps  sometimes  excites  increased  uterine  action,  through  the 
reflex  irritation  induced  by  the  presence  of  a  foreign  body  in  the 
vagina.  This  has  been  called  the  dynamical  action  of  the  forceps ; 
but  it  cannot  be  looked  upon  in  any  other  light  than  that  of  an  occa- 
sional accidental  result. 

The  circumstances  indicating  the  use  of  the  forceps  have  been  sepa- 
rately considered  elsewhere,  and  to  recapitulate  them  here  would  only 
lead  to  needless  repetition.  I  shall,  therefore,  now  merely  describe  the 
mode  of  using  the  instrument. 

Before  doing  so  it  is  well  to  repeat  what  has  already  been  said  as  to 
the  difference  between  what  may  be  termed  the  high  and  low  forceps 
operations.  The  application  of  the  instrument  when  the  head  is  low 
in  the  pelvis  is  extremely  simple ;  and  when  there  is  no  disproportion 
between  the  head  and  the  pelvis,  and  some  slight  traction  is  alone 
required  to  supplement  deficient  expulsive  power,  the  operation,  in  the 
hands  of  any  ordinarily  well  instructed  practitioner,  ought  to  be  per- 
fectly safe  both  to  the  mother  and  child.  It  is  very  different  when  the 
head  is  arrested  at  the  brim,  or  high  in  the  pelvis.  Then  the  applica- 
tion of  the  forceps  is  an  operation  requiring  much  dexterity  for  its 
proper  performance,  and  must  never  be  undertaken  without  anxious 
consideration.  It  is  because  these  two  classes  of  operations  have  been 
confused  that  the  use  of  the  instrument  is  regarded  by  many  with  such  ' 
unreasonable  dread. 


502  OBSTETRIC    OPERATIONS. 

Preliminary  Considerations. — Before  attempting  to  introduce  the 
forceps,  there  are  several  points  to  which  attention  should  be  directed. 

1st.  The  membranes  must,  of  course,  be  ruptured. 

2d.  For  the  safe  and  easy  application  of  the  instrument,  it  is  also 
advisable  that  the  os  should  be  fully  dilated,  and  the  cervix  retracted 
over  the  head.  Still  these  two  points  cannot  be  regarded,  as  many 
have  laid  down,  as  being  sine  qua  non.  Indeed,  we  are  often  com- 
pelled to  use  the  instrument  when,  although  the  os  is  fully  dilated,  the 
rim  of  the  cervix  can  be  felt  at  some  point  of  the  contour  of  the  head, 
especially  in  cases  in  which  the  anterior  lip  is  jammed  between  the 
head  and  the  pubes.  Provided  due  care  be  taken  to  guard  the  cervical 
rim  with  the  fingers  of  one  hand,  as  the  instrument  is  slipped  past  it, 
there  need  be  no  fear  of  injury  from  this  cause.  If  the  os  be  not  fully 
dilated,  but  is  sufficiently  open  to  admit  of  the  passage  of  the  forceps, 
the  operation,  under  urgent  circumstances,  may  be  quite  justifiable,  but 
it  must  necessarily  be  a  somewhat  anxious  one. 

3d.  The  position  of  the  head  should  be  accurately  ascertained  by 
means  of  the  sutures  and  fontanelles.  Unless  this  be  done,  the  opera- 
tion will  always  be  hap-hazard  and  unsatisfactory,  as  the  practitioner 
can  never  be  in  possession  of  accurate  knowledge  of  the  progress  of 
the  case.  It  may  be  that  the  occiput  is  directed  backward ;  and, 
although  that  does  not  centra-indicate  the  application  of  the  forceps, 
it  involves  special  precautions  being  taken. 

4th.  The  bladder  and  bowels  should  be  emptied. 

Question  of  Administering  Anaesthetics. — Before  proceeding  to 
operate,  the  question  of  anaesthesia  will  arise.  In  any  case  likely  to 
be  difficult  it  is  of  the  greatest  assistance  to  have  the  patient  completely 
under  the  influence  of  an  anaesthetic  to  the  surgical  degree,  so  as  to 
have  her  as  still  as  possible ;  but,  whenever  this  is  deemed  necessary, 
another  practitioner  should  undertake  the  responsibility  of  the  admin- 
istration. In  simple  cases  I  believe  it  is  better  to  dispense  with 
anaesthetics  altogether,  partly  because  they  are  apt  to  stop  what  pains 
there  are,  which  is  in  itself  a  disadvantage,  but  chiefly  because,  under 
partial  anaesthesia,  the  patient  loses  her  self-control,  is  restless,  and 
twists  herself  into  awkward  positions,  which  gives  rise  to  the  utmost 
difficulty  and  inconvenience  in  the  use  of  the  instrument.  Moreover, 
if  no  anaesthetic  be  given,  the  patient  can  assist  the  operator  by  placing 
herself  in  the  most  convenient  attitude. 

Description  of  the  Operation. — In  describing  the  method  of  apply- 
ing the  forceps,  I  shall  assume  that  we  have  to  do  with  the  simpler 
variety  of  the  operation,  when  the  head  is  low  in  the  pelvis.  Subse- 
quently I  shall  point  out  the  peculiarities  of  the  high  operation. 

As  to  the  position  of  the  patient,  I  believe  there  can  be  no  doubt  of 
the  superiority  of  that  which  is  usually  adopted  in  Great  Britain.  On 
the^Continent  and  in  America  the  forceps  is  always  employed  with  the 
patient  lying  on  her  back,  a  position  involving  much  needless  exposure 
of  the  person,  and  requiring  more  assistance  from  others.  In  certain 
cases  of  unusual  difficulty  the  position  on  the  back  is  of  unquestionable 
"utility,  but  we  may,  at  least,  commence" the  operation  in  the  usual  way 
and  subsequently  turn  the  patient  on  her  back  if  desirable. 


THE    FORCEPS. 


503 


Much  of  the  facility  with  which  the  blades  are  introduced  depends 
on  the  patient  being  properly  placed.  Hence,  although  it  gives  rise  to 
a  little  more  trouble  at  first,  I  believe  that  it  is  always  best  to  pay 
particular  attention  to  this  point,  whether  the  high  or  low  forceps 
operation  be  about  to  be  performed.  The  patient  should  be  brought 
quite  to  the  side  of  the  bed,  with  her  nates  parallel  to  and  projecting 
somewhat  over  its  edge.  The  body  should  lie  almost  directly  across 
the  bed,  and  nearly  at  right  angles  to  the  hips,  with  the  knees  raised 
toward  the  abdomen  (Fig.  173).  In  this  way  there  is  no  risk  of  the 
handle  of  the  upper  blade,  when  depressed  in  introduction,  coming  in 
contact  with  the  bed. 

Fro.  173. 


Position  of  patient  for  forceps  delivery  and  mode  of  introducing  lower  blade. 

Antiseptic  Precautions. — Previous  to  use  the  blades  should  be 
carefully  disinfected.  This  is  best  done  by  thoroughly  heating  them 
in  the  flame  of  a  spirit  lamp,  and  then  placing  them  in  hot  water  and 
creoliu.  They  should  then  be  lubricated  with  carbolized  vaseline  and 
placed  ready  to  hand. 

These  preliminaries  having  been  attended  to,  we  proceed  to  the 
introduction  of  the  blades,  sitting  by  the  side  of  the  bed,  opposite  the 
nates  of  the  patient. 

The  important  question  now  arises,  In  what  direction  are  the  blades 
to  be  passed  ?  The  almost  universal  rule  in  our  standard  works  is, 
that  they  must  be  passed  as  nearly  as  possible  over  the  child's  cars, 
without  any  reference  to  the  pelvic  diameters.  Hence,  if  the  head 
have  not  made  its  turn,  but  is  lying  in  one  oblique  diameter,  the  blades 
would  require  to  be  passed  in  the  opposite  oblique  diameter;  in  short, 
the  position  of  the  forceps,  as  regards  the  pelvis,  must  vary  according 
to  the  position  of  the  head.  Some  have  even  laid  down  the  rule  that 
the  forceps  is  contra-indicated  unless  an  ear  can  be  felt — a  rule  that 
would  very  seriously  limit  its  application,  as  in  many  cases  in  which 


504:  OBSTETRIC    OPERATIONS. 

it  is  urgently  required  it  is  a  matter  of  great  difficulty,  and  even  im- 
possibility, to  feel  the  ear  at  all.  It  is  admitted  that  in  the  high 
forceps  operation  the  blades  must  be  introduced  in  the  transverse 
diameter  of  the  pelvis,  without  relation  to  the  position  of  the  head. 
On  the  Continent  it  is  generally  recommended  that  this  rule  should  be 
applied  to  all  cases  of  forceps  delivery  alike,  whether  the  head  be  high 
or  low,  and  I  have  now  for  many  years  adopted  this  plan,  and  passed 
the  blades  in  all  cases,  whatever  be  the  position  of  the  head,  in  the 
transverse  diameter  of  the  pelvis,  without  any  attempt  to  pass  them 
over  the  bi-parietal  diameter  of  the  child's  head.  Dr.  Barnes  points 
out  with  great  force  that,  do  what  we  will,  and  attempt  as  we  may  to 
pass  the  blades  in  relation  to  the  child's  head,  they  find  their  way  to 
the  sides  of  the  pelvis,  and  that  the  marks  of  the  fenestrse  on  the  head 
always  show  that  it  has  been  grasped  by  the  brow  and  side  of  the 
occiput.  [']  Of  the  perfect  correctness  of  this  observation  I  have  no 
doubt ;  hence,  it  is  a  needless  element  of  complexity  to  endeavor  to 
vary  the  position  of  the  blades  in  each  case,  and  one  which  only  con- 
fuses the  inexperienced  practitioner,  and  renders  more  difficult  an 
operation  which  should  be  simplified  as  much  as  possible.  While, 
therefore,  it  is  of  importance  that  the  precise  position  of  the  head 
should  be  ascertained  in  order  that  we  may  have  an  intelligent  notion 
of  its  progress,  I  do  not  think  that  it  is  essential  as  a  guide  to  the 
introduction  of  the  forceps. 

Method  of  Introducing  the  Lower  Blade. — As  a  rule,  the  lower 
blade,  lightly  grasped  between  the  tips  of  the  index  and  middle  fingers 
and  the  thumb,  should  be  introduced  first.  Poised  in  this  way,  we 
have  perfect  command  over  it,  and  can  appreciate  in  a  moment  any 
obstacle  to  its  passage.  Two  or  more  fingers  of  the  left  hand  are 
introduced  into  the  vagina,  and  by  the  side  of  the  head,  as  a  guide. 
The  greatest  care  must  be  taken,  if  the  cervix  be  within  reach,  that 
they  are  passed  within  it,  so  as  to  avoid  the  possibility  of  injury. 

The  handle  of  the  instrument  has  to  be  elevated,  and  its  point  slid 
gently  along  the  palmar  surface  of  the  guiding  fingers  until  it  touches 
the  head  (Fig.'  173).  At  first  the  blade  should  be  inserted  in  the  axis 
of  the  outlet,  but  as  it  progresses  the  handle  must  be  depressed  and 
carried  backward.  As  it  is  pushed  onward  it  is  made  to  progress  by 
a  slight  side-to-side  motion,  and  it  is  of  the  utmost  importance  to  bear 
in  mind  that  the  greatest  gentleness  must  always  be  used.  If  any 
obstruction  be  felt,  wre  are  bound  to  withdraw  the  instrument,  partially 
or  entirely,  and  attempt  to  manoeuvre,  not  force,  the  point  past  it.  As 
the  blade  is  guided  on  in  this  way,  it  is  made  to  pass  over  the  con- 
vexity of  the  head,  the  point  being  always  kept  slightly  in  contact 
with  it,  until  it  finally  gains  its  proper  position.  When  fully  inserted 
the  handle  is  drawn  back  toward  the  perineum,  and  given  in  charge 
to  an  assistant.  The  insertion  must  be  carried  on  only  in  the  inter- 
vals between  the  pains,  and  desisted  from  during  their  occurrence ; 
otherwise  there  would  be  a  serious  risk  of  injuring  the  soft  parts  of 
the  mother. 

P  If  the  forceps  has  a  form  to  fit  the  sides  of  the  head,  it  will  not  rotate  within  the  blades.— ED.] 


THE    FORCEPS. 


505 


Introduction  of  the  Upper  Blade. — The  second  blade  is  passed 
directly  opposite  to  the  first,  and  is  generally  somewhat  more  difficult 
to  introduce,  in  consequence  of  the  space  occupied  by  the  latter.  It 
is  passed  along  two  fingers  directly  opposite  the  first  blade,  and  with 
exactly  the  same  precautions  as  to  direction  and  introduction,  except 
that  at  first  its  handle  has  to  be  depressed  instead  of  elevated  (Fig. 
174). 

The  handle  which  was  in  charge  of  the  assistant  is  now  laid  hold  of 
by  the  operator,  and  the  two  handles  are  drawn  together.  If  the 
blades  have  been  properly  introduced,  there  should  be  no  difficulty  in 
locking ;  but,  should  we  be  unable  to  join  them  easily,  we  must  with- 
draw one  or  other,  either  partially  or  entirely,  and  reintroduce  it  with 
the  same  precautions  as  before.  We  must  also  assure  ourselves  that 
no  hairs,  or  any  of  the  maternal  structures,  are  caught  in  the  lock. 


FIG.  174. 


Introduction  of  the  upper  blade. 

Method  of  Traction. — When  once  the  blades  are  locked  we  may 
commence  our  efforts  at  traction.  To  do  this  we  lay  hold  of  the 
handles  with  the  right  hand,  using  only  sufficient  compression  to  give 
a  firm  grasp  of  the  head  and  to  keep  the  blades  from  slipping.  The 
left  hand  may  be  advantageously  used  in  assisting  and  supporting  the 
right  during  our  efforts  at  extraction,  and,  at  a  late  stage  of  the  opera- 
tion, may  be  employed  in  relaxing  the  perineum  when  stretched  by 
the  head"  of  the  child.  Traction  must  always  be  made  in  reference  to 
the  pelvic  axes,  being  at  first  backward  toward  the  perineum  (Fig. 
175),  in  the  direction  of  the  axis  of  the  brim,  and  as  the  head  descends 
and  the  vertex  protrudes  through  the  vulva,  it  must  be  changed  to 
that  of  the  outlet  (Fig.  176).  If  the  axis-traction  forceps  is  used,  it 
is  to  be  borne  in  mind  that  traction  is  to  be  made  by  the  traction 
handle  only,  the  handles  of  the  instrument  itself  being  left  untouched 


506 


OBSTETRIC    OPERATIONS. 


after  they  are  locked  and  the  traction  rods  are  united.  By  keeping 
these  latter  parallel  to  the  handles  of  the  forceps,  traction  can  always 
be  made  in  the  proper  direction.  We  must  extract  only  during  the 
pains;  and,  if  these  should  be  absent,  we  must  imitate  them  by  acting 
at  intervals.  This  is  a  point  which  deserves  special  attention,  for 
there  is  no  more  common  error  than  undue  hurry  in  delivery. 

The  only  valid  objection  I  know  of  against  a  more  frequent  resort 
to  the  forceps  in  lingering  labor  is,  that  the  sudden  emptying  of  the 
uterus,  in  the  absence  of  pains,  may  predispose  to  hemorrhage ;  and  it 
cannot  be  denied  that  it  is  one  of  some  weight.  However,  if  due  care 
be  taken  to  operate  slowly,  and  to  allow  several  minutes  to  elapse  be- 
tween each  tractive  effort,  while  at  the  same  time  uterine  contractions 
are  stimulated  by  pressure  and  support,  this  need  not  be  considered 


FIG.  175. 


Forceps  in  position.    Traction  in  the  axis  of  the  brim,  downward  and  backward. 

a  contra-indication.  Besides  direct  traction  we  may  impart  to  the 
instrument  a  gentle  waving  motion  from  handle  to  handle,  which 
brings  into  operation  its  power  as  a  lever ;  but  this  must  be  done  only 
to  a  very  slight  extent,  and  must  always  be  subservient  to  direct  trac- 
tion. 

Proceeding  thus  in  a  slow  and  cautious  manner,  carefully  regulating 
the  force  employed  according  to  the  exigencies  of  the  case,  we  shall 
perceive  that  the  head  begins  to  descend ;  and  its  progress  should  be 
determined,  from  time  to  time,  by  the  fingers  of  the  unemployed  hand. 

When  the  head  lies  in  the  oblique  diameter,  as  it  descends,  in  con- 
sequence of  its  perfect  adaptation  to  the  pelvic  cavity  it  will  turn  into 
the  antero-posterior  diameter  without  any  effort  on  the  part  of  the 
operator,  provided  only  that  the  traction  be  sufficiently  slow  and 
gradual.  As  the  head  is  about  to  emerge,  it  is  necessary  to  raise  the 


THE    FORCEPS. 


507 


handles  toward  the  mother's  abdomen.  More  than  usual  care  is  re- 
quired to  prevent  laceration  of  the  perineum,  which  is  always  much 
stretched  (Fig.  176).  If,  as  often  happens,  the  pains  have  now  in- 
creased, and  the  perineum  be  very  thin  and  tense,  it  may  even  be  desir- 
able to  remove  the  blades  gently  and  leave  the  case  to  be  terminated 
by  the  natural  powers  ;  but  if  due  precautions  are  used  this  need  not 
be  necessary. 

The  peculiarities  of  forceps  delivery  in  occipito-posterior  positions 
have  already  been  discussed  (p.  335),  and  need  not  be  repeated. 

High  Forceps  Operations. — When  high  forceps  operation  has  been 
decided  on,  the  passage  of  the  blades  will  be  found  to  be  much  more 
difficult,  from  the  height  of  the  presenting  part,  the  distance  which 

FIG.  176. 


Last  stage  of  extraction.    The  handles  of  the  forceps  are  being  gradually  turned  upward 
toward  the  mother's  abdomen. 

they  must  pass,  and,  in  some  cases,  from  the  mobility  of  the  head 
interfering  with  their  accurate  adaptation.  The  general  principles  of 
introduction  and  of  traction  are,  however,  identical.  This  operation 
will  very  rarely  be  attempted  before  the  head  has  entered  or  become 
iixed  in  the  pelvic  brim,  for  if  it  be  freely  movable  above  the  brim, 
turning  is  preferable.  If,  however,  from  long  draining  away  of  the 
waters,  or  rigidity  of  the  uterus,  we  are  induced  to  attempt  the  opera- 
tion before  the  head  has  entered  the  brim,  it  must  be  fixed  as  much  as 
possible  by  abdominal  pressure.  In  guiding  the  blades  to  the  head 
special  care  must  be  taken  to  avoid  any  injury  of  the  soft  parts,  espe- 
cially if  the  cervix  be  not  completely  out  of  reach.  For  this  purpose 
it  may  even  be  advisable  to  introduce  the  entire  left  hand  as  a  guide, 


508  OBSTETRIC    OPERATIONS. 

so  as  to  avoid  any  possibility  of  injuring  the  cervix  from  not  passing 
the  instrument  under  its  edge. 

Peculiar  Method  of  Introducing1  the  Blades. — Some  authors 
advise  that,  in  such  eases,  the  blade  should  be  introduced  at  first  oppo- 
site the  sacrum,  until  the  point  approaches  its  promontory.  It  is  then 
made  to  sweep  round  the  pelvis,  under  the  protecting  fingers,  till  it 
reaches  its  proper  position  on  the  head.  This  plan  is  advocated  by 
Ramsbotham,  Hall  Davis,  and  other  eminent  practical  accoucheurs, 
and  it  is  certainly  of  service  in  some  cases  of  difficulty ;  especially 
when,  from  any  reason,  it  is  not.  possible  to  draw  the  nates  over  the 
edge  of  the  bed,  when  the  necessary  depression  of  the  handle  of  the 
upper  blade  is  difficult  to  effect.  It  involves,  however,  a  somewhat 
complicated  manoeuvre,  and  it  is  seldom  that  the  blades  cannot  be 
readily  introduced  in  the  usual  way. 

In  locking,  the  slightest  approach  to  roughness  must  be  carefully 
avoided,  for  the  extremities  of  the  blades  are  now  within  the  cavity  of 
the  uterus,  and  serious  injury  might  easily  be  inflicted.  If  difficulty 
be  met  with,  rather  than  employ  any  force,  one  of  the  blades  should 
be  withdrawn  and  reintroduced  in  a  more  favorable  direction.  If 
the  blades  have  shanks  of  sufficient  length,  there  should  be  no  risk  of 
including  the  soft  parts  of  the  mother  in  the  lock,  which,  in  a  badly 
constructed  instrument,  is  an  accident  not  unlikely  to  occur. 

Method  of  Traction. — After  junction,  traction  must  at  first  be 
altogether  in  the  axis  of  the  brim,  and  to  effect  this  the  handles  must 
be  pressed  well  backward  toward  the  perineum.  As  the  head  descends 
it  will  probably  take  the  usual  turn  of  itself,  without  effort  on  the 
part  of  the  operator,  and  the  direction  of  the  tractive  force  may  be 
gradually  altered  to  that  of  the  axis  of  the  outlet.  If  the  pains  be 
strong  and  regular,  and  there  be  no  indication  for  immediate  delivery, 
we  may  remove  the  forceps  after  the  head  has  descended  upon  the 
perineum,  and  leave  the  conclusion  of  the  case  to  Nature.  This  course 
may  be  especially  advisable  if  the  perineum  and  soft  parts  be  unusually 
rigid  ;  but  generally  it  is  better  to  terminate  labor  without  removing 
the  instrument. 

Possible  Dangers  of  Forceps  Delivery. — Before  concluding  this 
subject,  reference  may  be  made  to  the  possible  dangers  of  the  opera- 
tion. I  would  here  again  insist  on  the  importance  of  distinguishing 
between  the  high  and  low  forceps  operations,  which  have  been  so 
unfortunately  and  unfairly  confounded.  Reasons  have  already  been 
given  for  rejecting  the  statistics  of  the  risks  attending  forceps  delivery 
in  the  latter  class  of  cases  (p.  363).  A  formidable  catalogue  of 
dangers,  both  to  mother  and  child,  might  easily  be  gathered  from  our 
standard  works  on  obstetrics.  Among  the  former  the  principal  are 
lacerations  of  the  uterus,  vagina,  and  perineum  ;  rupture  of  varicose 
veins,  giving  rise  to  thrombus ;  pelvic  abscess  from  contusion  of  the 
soft  parts  ;  subsequent  inflammation  of  the  uterus  or  peritoneum  ; 
tearing  asunder  of  the  joints  and  symphyses ;  and  even  fracture  of  the 
pelvic  bones.  A  careful  analysis  of  these,  such  as  has  been  so  well 
made  by  Drs.  Hicks  and  Phillips,1  proves  beyond  doubt  that  the 

1  Obst.  Trans.,  1872,  vol.  xiii.,  p.  55. 


THE    FORCEPS.  509 

application  of  the  instrument  is  not  so  much  concerned  in  their 
production  as  the  protraction  of  the  labor,  and  the  neglect  of  the  prac- 
titioner in  not  interfering  sufficiently  soon  to  prevent  the  occurrence 
of  the  evil  consequences,  afterward  attributed  to  the  operation  itself. 
Many  of  these  will  be  found  to  arise  from  the  prolonged  pressure  on 
the  soft  parts  within  the  pelvis  and  the  subsequent  inflammation  or 
sloughing.  To  these  causes  may  be  referred  with  propriety  most  cases 
of  vesico-vaginal  fistula  (p.  459),  peritonitis,  and  metritis  following 
instrumental  labor. 

Lacerations  and  similar  accidents  may,  however,  result  from  an 
incautious  use  of  the  instrument.  Slight  lacerations  of  the  mucous 
membrane  of  the  vagina  are  probably  far  from  uncommon.  But  if 
these  cases  were  closely  examined  it  would  be  found  that  the  fault  lay 
not  in  the  instrument,  but  in  the  hand  that  used  it.  Either  the  blades 
were  introduced  without  due  regard  to  the  axes  of  the  pelvis,  or  they 
were  pushed  forward  with  force  and  violence,  or  an  instrument  was 
employed  unsuitable  to  the  case  (such  as  a  short  straight  forceps  when 
the  head  was  high  in  the  pelvis),  or  undue  haste  and  force  in  delivery 
were  used.  It  would  be  manifestly  unfair  to  lay  the  blame  of  such 
results  upon  the  forceps,  which,  in  the  hands  of  a  more  judicious  and 
experienced  practitioner,  would  have  effected  the  desired  object  with 
perfect  safety.  The  instrument  is  doubtless  unsafe  in  the  hands  of 
anyone  who  does  not  understand  its  use,  just  as  the  scalpel  or  ampu- 
tating knife  would  be  in  the  hands  of  a  rash  and  inexperienced 
surgeon.  The  lesson  to  be  learnt  seems  to  be,  clearly,  not  that  the 
dangers  should  deter  us  from  the  use  of  the  forceps,  but  that  they 
should  induce  us  to  study  more  carefully  the  cases  in  which  it  is 
applicable  and  the  method  of  using  it  with  safety. 

Possible  Risks  to  the  Child. — The  dangers  to  the  child  are,  prin- 
cipally, lacerations  of  the  integuments  of  the  scalp  and  forehead; 
contusion  of  the  face ;  partial,  but  temporary,  paralysis  of  the  face 
from  pressure  of  a  blade  on  the  facial  nerve ;  depression  or  fracture  of 
the  cranial  bones ;  injury  to  the  brain  from  undue  pressure  of  the 
blades.  These  evils  are  of  rare  occurrence,  and,  when  they  do  happen, 
generally  result  from  improper  management  of  the  operation — such  as 
undue  compression,  the  use  of  improper  instruments,  or  excessive  and 
ill-directed  efforts  at  traction — and  cannot,  therefore,  be  considered  as 
in  any  way  contra-indicating  the  use  of  the  instrument.  Many  of 
the  more  common  results,  such  as  slight  abrasions  of  the  scalp  or 
paralysis  of  the  face,  are  transitory  in  their  nature  and  of  no  real 
consequence. 

[The  Forceps  in  America. — Although  the  obstetrical  forceps  was 
first  used  in  England,  other  countries  in  the  march  of  improvement 
have  made  great  changes,  not  only  in  the  original  forms,  but  in  the 
manner  of  use,  and  various  shapes,  as  well  as  different  positions  of  the 
woman  in  application,  have  become  in  a  measure  national.  With  the 
exception  of  having  adopted  almost  exclusively  the  French  and  German 
dorsal  decubitus  in  making  use  of  the  instrument,  we  have  become  in  a 
measure  eclectic  in  the  selection  of  the  latter  :  medical  schools,  accouch- 
eurs, and  local  obstetrical  societies  influencing  students  and  the  junior 


510  OBSTETRIC    OPERATIONS. 

members  of  the  profession  to  adopt  the  French,  German,  English,  or 
American  style,  as  the  case  may  be,  the  forceps  themselves  bearing  the 
names  of  the  several  inventors  or  compilers ;  for  some  are  a  true  com- 
pilation— the  blade  from  one  contriver;  fencstral  openings,  another; 
pelvic  curve,  a  third;  width,  a  fourth;  shanks,  a  fifth;  method  of 
locking,  a  sixth,  etc.  For  this  reason  the  late  Prof.  Hodge  named  his 

•      • 

forceps  the  eclectic,  although  in  some  respects  entirely  original,  particu- 
larly in  the  long  superimposed  shanks — a  great  improvement  for  oper- 
ating at  the  superior  strait  and  avoiding  the  painful  stretching  of  the 
posterior  commissure  of  the  vulva.  Dr.  Hodge  expended  a  great  deal 
of  thought  and  money  in  perfecting  his  forceps,  and  the  various  steps 
in  the  process  were  marked  by  a  new  form,  until,  from  a  heavy,  clumsy 
instrument,  he  gradually  evolved  what  was  at  one  time  regarded  as  a 
Avonderful  improvement  upon  the  forceps  of  France  and  England. 

A  contemporary  of  Prof.  Hodge,  the  late  Prof.  David  D.  Davis,  of 
London,  was  equally  anxious  to  perfect  the  instrument,  and  turned 
his  attention  especially  to  making  the  blades  light,  open,  and  to  fit  the 
sides  of  the  foetal  head  so  as  to  enable  traction  to  be  made  without 
much  pressure  or  leaving  any  mark  on  the  child's  scalp.  There  is  a 
principle  of  mechanics  involved  in  his  instrument  which  he  studied  to 
perfect  by  moulding  the  blades  upon  an  iron  foetal  head  so  as  to  obtain 
considerable  coaptating  surface,  and  thus  by  increase  of  friction  to 
avoid  undue  and  dangerous  pressure.  The  Davis  blade  soon  began  to 
effect  changes  in  the  form  of  American  forceps,  and  by  the  addition  of 
long  handles  and  some  alterations  of  shape,  weight,  and  curve  became 
a  leading  feature  in  those  bearing  the  names  of  Prof.  Wallace,  of  the 
Jefferson  Medical  College,  Dr.  Bethel,  and  Albert  H.  Smith,  all  of 
this  city.  The  short  Davis  instrument  was  a  great  favorite  with  the 
late  Prof.  Meigs  and  Dr.  William  Harris,  both  largely  engaged  in 
obstetrical  practice  as  well  as  teaching ;  and  many  a  delicate  woman 
with  wasting  forces  was  aided  in  her  delivery  at  their  hands,  and  was 
surprised  to  find  no  mark  on  the  baby's  head,  and  that  her  own 
sufferings  could  be  so  gently  and  safely  relieved. 

Although  such  was  the  estimation  of  the  Davis  blade,  and  still  is  in 
many  parts  of  our  country,  it  does  not  appear  to  have  retained  its 
popularity  or  been  adopted,  as  its  mechanical  perfection  would  lead 
one  who  appreciates  it  to  suppose  it  would  have  been.  In  Great 
Britain  the  favorite  forms  now  in  use  are  but  a  very  slight  improve- 
ment upon  the  forceps  of  a  hundred  years  ago  except  in  finish  and 
material,  the  open  fenestrse  and  bevelled  blades  of  Davis  being  declined 
in  favor  of  the  looped  fenestrse  and  flat-edged  blades  in  use  when  he 
made  his  experiments  and  changes.  This  appears  to  have  grown  out 
of  a  practice  which  has  been  largely  adopted  in  Germany,  Great 
Britain,  and  many  parts  of  the  United  States  in  applying  the  forceps 
to  the  foetal  head,  the  blades  being  introduced  at  the  sides  of  the 
pelvis  without  much  reference  to  the  position  which  the  head  occupies. 
As  compression  is  objected  to,  the  blades  are  made  long  and  widely 
separated  (three  and  a  quarter  to  three  and  a  half  inches),  and  the 
handles  short,  so  as  not  to  allow  of  much  leverage.  As  the  blades  do 
not  fit  the  head,  the  mechanism  of  labor  as  taught  by  Hodge  has  been 


THE    FORCEPS.  511 

much  simplified,  as  it  is  not  necessary  to  learn  all  the  oblique  fittings 
of  the  fenestrse  over  the  parietal  protuberances  or  ears.  Dr.  Meigs 
used  to  tell  the  students  that  the  forceps  was  the  child's  instrument, 
and  should  be  used  as  a  tractor ;  and  for  this  reason  he  advocated  the 
use  of  the  Davis  blades  against  those  of  Siebold,  Levret,  Baudelocque, 
and  Haighton,  employed  generally  in  our  country  fifty  years  ago. 
His  language  is  not  very  complimentary  to  what  he  denominates  by 
distinction  the  mother's  instrument,  the  form  being  better  adapted  for 
saving  the  woman  than  the  fetus. ['] 

At  the  present  day  we  have  two  general  orders  of  forceps  in  use  in 
the  United  States,  under  each  of  which  may  be  placed  a  vast  number 
of  special  varieties  which  are  simply  changes  upon  one  or  the  other 
general  type  according  to  the  fancy  of  the  inventor.  At  the  head  of 
one  type  may  be  placed  the  long  forceps  of  Prof.  Hodge,  designed  to 
be  adapted  to  the  sides  of  the  child's  head  in  all  possible  cases ;  and  of 
the  other,  those  of  Prof.  James  Y.  Simpson,  of  Edinburgh,  or  their 
modification  by  Profs.  Elliot  and  Bedford,  of  New  York,  intended  to 
be  used  as  tractors,  and  applied  in  reference  to  the  sides  of  the  mother's 
pelvis,  rather  than  to  those  of  the  infant's  head.[2] 

Taking  the  long  forceps  of  Levret  and  Baudelocque  as  improved 
and  modified  by  Hodge,  with  the  blades  of  Prof.  Davis  as  a  substitute, 
and  handles  of  less  curve  than  those  of  Hodge,  and  we  have  the  long 
forceps  of  the  late  Prof.  Ellerslie  Wallace,  of  Jefferson  Medical  College, 
at  one  time  a  very  favorite  variety  and  largely  used.  Next  in  order 
are  the  instruments  of  Hodge,  Davis,  and  Simpson,  Elliot,  Bedford, 
and  a  few  others — in  all  about  a  dozen  forms  that  vary  in  popularity. 
The  improvement  of  the  late  Prof.  Elliot  upon  the  instrument  of 
Simpson  consists  in  narrowing  and  lengthening  the  shanks,  widening 
somewhat  the  fenestrae,  elongating  the  blades,  giving  greater  security 
against  slipping  in  the  handles,  and  gauging  the  distance  between  the 
blades  by  a  milled-head  screw-stop  in  the  end  of  the  handles ;  the 
shanks  and  blades  are  an  exact  counterpart  of  the  Miller  forceps  of 
England,  which  appeared  about  the  same  time  (1858). 

The  Hodge  forceps  was  based  in  its  contrivance  upon  the  following 
points :  1.  The  instrument,  should  be  shaped  to  the  contour  of  the 
foetal  head,  and  have  sufficient  play  to  allow  of  compression  where  the 
pelvis  is  too  narrow  for  the  head  to  pass  in  its  normal  condition. 
2.  The  blades  should  be  so  arranged  in  reference  to  the  shanks  and 
handles  as  to  enable  them  to  seize  the  head  of  the  foetus  in  its  bi-parietal 
diameter  at  the  superior  strait,  and  be  drawn  upon  in  the  direction  of 
the  curve  of  the  pelvic  canal  until  the  delivery  is  complete.  3.  The 
long  forceps  ought  to  be  competent  to  act  either  at  the  superior  strait 
of  the  pelvis,  in  its  cavity,  or  at  its  outlet,  so  as  to  avoid  a  multiplicity 
of  instruments  and-  their  attendant  expense.  And,  4.  The  instru- 
ment should  not  cut  the  scalp  of  the  child  if  properly  adjusted,  or 
injure  the  soft  parts  of  the  mother. 

It  would  be  folly  to  claim  that  all  this  could  be  or  has  been  accom- 

f1  Obstetrics,  p.  540.] 

P  The  Simpson  forceps,  and  the  method  of  application  in  reference  to  the  pelvis  Instead  of  the 
head,  appear  to  be  growing  very  largely  in  favor  in  America.— ED.  J 


512 


OBSTETRIC    OPERATIONS. 


p]  ished,  as  there  must  necessarily  be  exceptional  cases  in  all  the  points 
given ;  hence  the  contrivance  of  the  forceps  of  Taruier  and  Cleemann 
for  certain  presentations  above  the  superior  strait,  and  the  long  and 
short  convertible  instruments  of  a  few  inventors.  There  are  many 
cases  of  labor  in  the  higher  walks  of  life  where,  although  there  is  no 
obstruction,  still  the  women  require  manual  or  instrumental  assistance, 
as  they  cannot  deliver  themselves  for  want  of  sufficient  contractile 
muscular  force.  Such  women  require  that  the  forceps  used  should  be 


FIG.  177. 


FIG.  178. 


FIG.  179. 


Hodge  forceps. 


Wallace  forceps. 


Davis  forceps. 


easily  introduced — should  act  simply  as  tractors,  control  the  movement 
of  the  foetal  head  by  being  well  fitted  to  its  shape,  and  leave  no  effect 
upon  the  scalp  or  vulva.  Although  these  requisites  may  be  filled  by 
the  Hodge  instrument,  it  is  this  class  of  cases  that  has  demanded  a 
lighter  and  more  roomy  pair  of  forceps,  such  as  that  devised  by  Davis. 
As  the  teaching  of  the  Jefferson  Medical  College  under  Dr.  Meigs 
favored,  as  we  have  stated,  the  forceps  of  Davis,  so  his  successor,  Prof. 
Wallace,  in  carrying  out  in  a  measure  the  same  views,  combined  the 
blades  of  the  Davis  pattern  with  the  long  handles  of  Hodge  in  con- 
triving what  is  known  as  the  "  Wallace  forceps."  As  compared  with 


THE    FORCEPS.  513 

the  Hodge  instrument,  it  is  one  inch  shorter  (fifteen  inches  against 
sixteen) ;  the  blades  are  of  the  same  length  (six  inches)  ;  the  fenestrse 
are  more  open ;  the  shanks  are  only  half  the  length,  giving  much 
greater  compressing  power ;  and  the  handles  are  of  the  same  measure- 
ment from  pivot  to  hooks.  Both  have  the  Siebold  lock,  over  which 
we  believe  the  broad-topped  button  and  notch  to  possess  some  advan- 
tages ;  and  the  Wallace  is  somewhat  heavier  than  the  Hodge,  which 
should  weigh  seventeen  ounces. 

The  short  Davis  instrument  made  for  Prof.  Meigs  under  direction 
of  the  inventor  weighed  ten  and  three-quarters  ounces  and  measured 
twelve  inches  in  length  ;  fenestrse,  five  inches  long,  two  inches  wide ; 
blades  separated  two  and  three-quarters  inches ;  handles,  four  and  one- 
quarter  inches  to  lock,  which  Avas  of  the  Smellie  or  English  pattern. 
A  pair  in  possession  of  the  editor  is  thirteen  and  one-half  inches  long, 
with  five-inch  handles,  a  button  lock,  two-inch  close-set  shanks,  and 
six  and  one-half  inch  blades.  I  believe  the  changes  are  decided  im- 
provements, especially  the  lock  and  elongated  handles.  It  has  answered 
admirably  in  adynamic  cases  requiring  only  a  few  pounds  of  tractile 
assistance.  The  Davis  blades  have  been  added  to  long  handles,  and 
the  whole  made  of  steel  and  marvellously  light,  at  the  special  request 
of  a  few  accoucheurs,  who  wished  them  to  aid  in  some  cases  of  arrest 
at  the  perineum. 

The  late  Prof.  George  T.  Elliot,  of  New  York,  who  received  much 
of  his  practical  obstetrical  training  in  the  Dublin  Lying-in  Hospital, 
imbibed  the  teachings  of  the  English  school,  and  became  impressed 
with  the  value  of  the  system  as  taught  by  Simpson,  upon  the  principle 
of  whose  forceps,  modelled  somewhat  after  that  of  the  late  Prof.  Gun- 
ning S.  Bedford,  of  New  York,  he  in  1858  presented  to  the  medical 
profession  the  instrument  that  bears  his  name.  The  forceps  of  Prof. 
Bedford  has  a  traction-ring  on  each  side  where  the  Elliot  has  a  cornu, 
has  a  button  joint  instead  of  a  Smellie,  has  no  screw  top,  and  has 
diverging  instead  of  superimposed  shanks ;  these  points  have  generally 
been  considered  as  improvements. 

The  Sawyer  Forceps. — This  is  the  lightest  of  all  the  varieties  of 
the  short  forceps,  weighing  but  five  ounces,  and  measuring  nine  and 
three-quarters  inches  in  length  ;  the  handle  being  three  inches,  shank 
one  and  a  half,  and  chord  of  blade-curve  five  and  a  quarter.  The 
blades  are  one  and  a  half  inches  wide,  with  oval  fenestree  seven-eighths 
of  an  inch  wide,  and  separated  two  and  five-eighths  inches  at  their 
widest  part  and  three-quarters  of  an  inch  at  the  tips.  This  instrument 
was  invented  twelve  years  ago  by  Prof.  Edw.  Warren  Sawyer,  of 
Rush  Medical  College,  Chicago,  and  has  been  highly  commended  by 
Prof.  Byford  and  others.  The  forceps  has  the  blades  of  Davis,  super- 
imposed shanks  of  Hodge,  and  lock  of  Smellie,  with  hard-rubber  plates 
moulded  hot  upon  the  handles.  The  several  parts  have  been  some- 
what modified,  the  object  being  to  secure  a  tractor  for  cases  of  deficient 
expulsive  force  where  the  foetal  head  is  low  in  the  pelvis. 

Professor  Sawyer  says:  "In  the  labors  to  which  my  forceps  is 
applicable  it  is  not  necessary  for  the  operator's  body  to  be  in  line  with 
the  pelvic  axis.  My  mode  of  procedure  is  the  following:  The  woman 

33 


514 


OBSTETRIC    OPERATIONS. 


is  placed  upon  her  back  aiid  drawn  to  the  edge  of  the  bed ;  the  outside 
leg  is  now  flexed ;  beneath  this  flexed  extremity  and  the  bed-covering 
I  apply  the  forceps — often  using  but  one  hand  in  the  operation.  When 
the  instrument  is  locked,  I  grasp  the  handle  in  such  a  manner  that 
the  palm  of  the  hand  looks  upward ;  one  hook  then  rests  naturally 
upon  the  extensor  surface  of  the  first  phalanx  of  the  index  finger, 
while  the  other  hook  rests  upon  a  corresponding  part  of  the  thumb. 
When  thus  adjusted,  I  lift  the  head  from  the  pelvic  outlet,  at  the 
same  time  invoking  the  pendulum  movement  if  desired.  At  this 


FIG.  180. 


FIG.  181. 


Elliot  forceps. 


Sawyer  forceps. 


moment  the  advantage  of  the  hooked  handle  is  very  apparent  to  the 
operator."  .  .  .  "All  practitioners  must  have  often  felt,  during 
the  last  moments  of  labor,  when  the  uterus  and  the  mother  seemed 
fatigued,  the  need  of  a  little  help  to  the  expulsive  powers.  The  ordi- 
nary instruments  are  too  formidable  to  be  used  at  the  last  moment,  and 
it  is  then  that  this  little  forceps  is  useful." 

The  mechanism  of  instrumental  delivery  is  much  simplified  by 
applying  the  forceps  to  whatever  parts  of  the  foetal  head  may  be  oppo- 
site the  sides  of  the  pelvis,  but  it  is  very  questionable  whether  it  is  the 
scientific  method  or  the  safer  for  the  child.  With  one  blade  over  the 
side  of  the  occiput,  and  the  other  over  that  of  the  forehead — which  is 


THE    FORCEPS.  515 

the  manner  of  seizure  in  oblique  positions  of  the  vertex — we  certainly 
have  not  a  very  secure  hold  and  run  some  risk  of  injury  to  the  foetus. 
The  advocates  of  this  system  claim  that  they  use  no  compression,  only 
a  simple  traction ;  which  may  be  true  in  one  sense,  but  amounts  to  the 
same  in  effect,  else  how  could  Dr.  Elliot,  by  traction  with  great  force, 
straighten  out  one  of  the  blades  of  his  Simpson  forceps,  as  related  in 
the  New  York  Journal  of  Medicine  for  September,  1858,  p.  161,  in  the 
paper  which  he  presented  describing  his  new  forceps  and  a  number  of 
cases  in  which  he  had  tested  them?  It  makes  but  little  difference 
whether  we  compress  the  head  before  we  begin  to  pull,  or  pull  so  as  to 
wedge  the  head  between  the  blades,  and  thus  compress  it,  except  as  to 
the  difference  of  fit  in  the  two  instances  ;  the  adjusted  and  even  pressure 
being  the  less  likely  to  injure  the  foetus.  I  have  always  believed  that 
the  forceps  should  fit  the  head,  and  that  the  student  should  be  taught 
how  to  accomplish  it  correctly  in  the  various  positions  of  the  foetus. 
If  the  student  has  a  mechanical  turn  of  mind,  a  delicate  sense  of  touch, 
and  a  clear  head,  he  will  soon  learn  ;  if  he  is  not  a  mechanic,  he  will 
be  forced  to  adopt  a  more  simple  method  of  delivery.  In  a  large  city 
there  are  but  few  first-class  obstetrical  manipulators  as  a  general  rule, 
and  they  are  usually  well  known  as  such,  for  the  reason  that  but  few 
have  all  the-  requisites  to  enable  them  to  achieve  notoriety ;  and  yet 
there  are  hundreds  who  can  deliver  a  woman  with  forceps  moderately 
well.  To  one  the  mechanism  of  Hodge  is  a  simple  matter  and  soon 
mastered ;  to  another  it  is  a  useless  complication,  and  he  prefers  the 
more  simple  system.  Hence  the  great  differences  between  obstetricians 
as  to  the  best  instrument  and  the  best  method  of  application.  Some 
of  the  vast  array  of  patterns  have  decided  merit  and  display  much 
mechanical  skill,  while  others  serve  only  to  amuse  the  educated  ex- 
aminer. One  obstetrician,  after  the  manner  of  Elliot,  uses  a  variety 
of  forceps  one  after  another  in  the  case,  and  pulls  with  great  force, 
while  another  confines  his  work  almost  to  one  instrument,  adjusts  it 
easily,  pulls  moderately,  and  seldom  fails.  There  are  no  doubt  excep- 
tions, but  certainly  the  most  delicate  manipulators  we  have  seen 
believed  in  and  practised  the  teachings  of  Hodge  and  Meigs.  There 
may  be  cases  where  it  might  be  well  to  practise  the  method  of  Simpson, 
but  we  cannot  see  why  his  plan  of  delivery  should  be  exclusively  used 
on  any  mode  of  scientific  reasoning. 

I  present  a  series  of  illustrations  showing  the  American  method  of 
delivery  with  the  forceps,  the  position,  as  will  be  seen,  being  that  of 
France  and  Germany — on  the  back.  When  it  is  decided  to  use  the 
forceps,  in  almost  all  cases  in  the  United  States  the  patient  is  brought 
to  the  edge  of  the  bed  on  her  back,  with  her  nates  close  to  the  edge, 
her  feet  on  two  chairs,  and  her  knees  widely  separated,  as  in  the  illus- 
tration. The  patient  is  covered  with  a  sheet,  or  with  a  heavier  cover- 
ing if  in  winter,  and  there  is  no  necessity  of  exposure,  as  the  whole 
manipulation  may  be  done  by  the  sense  of  touch.  The  position  is  by 
far  the  most  convenient  for  the  obstetrician,  and  enables  him  much 
more  easily  to  keep  in  his  mind  all  the  anatomical  relations  of  the 
foetus  and  pelvis  than  when  in  the  English  decubitus.  We  study  the 
anatomy  with  the  subject  on  the  back,  and  the  mechanism  of  labor  in 


516 


OBSTETRIC    OPERATIOXS. 


front  of  the  pelvis  or  manikin ;  then  why  complicate  matters  by  a 
change  of  position,  which,  to  say  the  least,  is  a  very  awkward  one, 
particularly  in  introducing  the  long  forceps,  setting  it  according  to  the 
instructions  of  Hodge,  and  carrying  it  forward  between  the  thighs  as 
the  head  emerges  ?  I  have  used  the  short  forceps  in  an  exhausted  case 
with  the  woman  on  her  side,  but  found  it  much  less  convenient  for  the 
various  movements,  although  I  soon  delivered  the  foetus.  As  to  the 
question  of  exposure,  there  is  less  in  appearance  than,  in  fact,  in  the 


FIG.  182. 


Application  of  the  forceps  at  the  inferior  strait. 

English  position  in  many  cases.  If  the  patient  and  nurse  are  fastidi- 
ous and  careful  during  the  use  of  the  forceps,  the  accoucheur  can 
manage  without  his  eyes  in  a  large  proportion  of  cases ;  but  the  fault 
of  exposure  lies  more  frequently  in  the  temporary  reckless  indifference 
begotten  of  pain  and  suffering  in  the  woman,  than  in  any  act  of  the 
accoucheur  if  inclined  to  spare  the  feelings  of  his  patient  as  much  as 
possible. 

The  long  forceps,  with  its  pelvic  curve,  was  specially  designed  for 
use  at  the  superior  strait  of  the  pelvis,  the  curve  of  the  blades,  as  in 


THE    FORCEPS. 


517 


the  Davis  instrument  modified  by  Wallace,  being  intended  to  corre- 
spond with  the  direction  of  the  occipito-mental  diameter  of  the  foetal 
head.  The  long  superimposed  shanks  of  several  varieties  of  the  long 
forceps  will  here  be  found  valuable,  as  the  lock  is  not  introduced  or 
the  posterior  commissure  of  the  vulva  widely  stretched.  If  the  head 
is  entirely  above  the  strait,  the  line  of  the  blades  must  be  changed 


FIG,  183. 


Application  of  the  forceps  with  the  head  at  the  superior  strait,  the  left  blade  held  In  place 

by  an  assistant. 

correspondingly,  in  order  to  apply  them  properly  and  keep  the  line 
of  traction  within  the  coccyx ;  and  even  then,  to  draw  in  the  proper 
direction,  the  left  hand  must  act  at  first  in  a  backward  direction  from 
the  lock,  while  the  right  brings  the  handles  downward,  forward,  and 
then  upward ;  both  hands  describing  a  curve,  but  that  of  the  right 
being  much  the  greater.  The  peculiar  forceps  of  Tarnier,  Poullet, 
and  Cleemann,  being  designed  to  meet  this  form  of  exigency,  may  be 
brought  into  requisition. 


518 


OBSTETRIC    OPERATIONS. 


In  latter  years  it  lias  become  much  more  common  than  formerly  to 
introduce  the  forceps  into  the  uterus  before  it  is  fully  dilated,  in  conse- 
quence of  the  success  claimed  for  the  plan  as  carried  out  in  the  Dublin 
Lying-in  Hospital.  As  this  should  never  be  done  where  the  os  is  not 
readily  dilatable,  and  requires  much  skill  in  execution,  it  is  not  safe  to 
recommend  its  general  adoption  in  cases  of  delay  in  private  practice. 

The  forceps  should  not  be  introduced  with  any  force,  but  the  left 
blade  should  be  slid  in  gently  and  with  a  spiral  motion,  and  then  the 
right,  care  being  taken  that  they  should  also  lock  without  force,  which 

FIG.  184. 


Direction  of  the  forceps  as  the  head  is  being  delivered. 

they  will  do  if  properly  adjusted.  Traction  is  to  be  exerted  slowly  and 
during  a  pain,  the  whole  movement  being  made  to  correspond  with  the 
natural  one  as  closely  as  possible. 

As  the  fetal  head  comes  under  the  arch  of  the  pubes  the  handles  of 
the  forceps  must  rise  more  and  more  from  the  bed,  until  at  last  they 
are  over  the  abdomen  as  the  head  emerges  from  the  perineum.  This 
last  movement  of  instrumental  delivery  should  be  a  very  slow  one,  for 
fear  of  rupture.  It  has  been  proposed  to  remove  the  blades  before 
delivery  is  complete ;  but  there  is  no  occasion  for  this  if  the  forceps  is 
applied  to  the  sides  of  the  head  over  the  parietal  protuberances,  as, 
where  these  protrude  and  the  blades  are  flat  and  thin,  there  is  very 
little  additional  space  required.  With  such  instruments  as  the  old 


THE    VECTIS.  —  THE    FILLET.  519 

Levret,  Baudelocque,  and  Rohrer  forceps,  with  looped  or  kite-shaped 
fenestrre  and  thick  edges,  this  was  a  much  more  imperative  direction 
than  with  the  better  instruments  of  the  present  day.  With  a  Sawyer 
forceps  the  perineum  ought  to  be  safer  and  under  better  control  than 
without.  When  the  perineum  is'thought  to  be  in  danger,  the  process 
of  distention  should  be  retarded  through  two  or  three  pains,  or  even 
more  if  required,  instead  of  drawing  the  head  through  at  once. 

After  the  head  is  delivered,  if  the  cord  is  not  around  the  neck  and 
therefore  in  danger  from  pressure,  the  body  should  be  allowed  to 
remain  until  the  uterus  has  well  contracted  upon  it,  for  fear  of  hemor- 
rhage after  delivery,  from  uterine  inertia. — ED.] 


CHAPTER    IY. 

THE  VECTIS.— THE  FILLET. 

The  Vectis. — In  connection  with  the  subject  of  instrumental  de- 
livery, it  is  essential  to  say  something  of  the  use  of  the  vectis,  on 
account  of  the  value  which  was  formerly  ascribed  to  it,  which  was  at 
one  time  so  great  in  England  that  it  became  the  favorite  instrument 
in  the  metropolis  ;  Denman  saying  of  it  that  even  those  who  employed 
the  forceps  were  "very  willing  to  admit  the  equal,  if  not  superior, 
utility  and  convenience  of  the. vectis."  Even  at  the  present  day  there 
are  practitioners  of  no  small  experience  who  believe  it  to  be  of  occasional 
great  utility,  and  use  it  in  preference  to  the  forceps  in  cases  in  which 
slight  assistance  only  is  required.  In  spite,  however,  of  occasional 
attempts  to  recommend  its  use,  the  instrument  has  fallen  into  disfavor, 
and  may  be  said  to  be  practically  obsolete. 

Nature  of  the  Instrument. — The  vectis,  in  its  most  approved  form, 
consists  of  a  single  blade,  not  unlike  that  of  a  short  straight  forceps, 
attached  to  a  wooden  handle.  A  variety  of  modifications  exists  in  its 
shape  and  size.  The  handle  has  been  occasionally  manufactured,  for 
the  convenience  of  carriage,  with  a  hinge  close  to  the  commencement 
of  the  blade  (Fig.  185),  or  with  a  screw  at  the  point  where  the  handle 
and  blade  join.  The  power  of  the  instrument,  and  the  facility  of 
introduction,  depend  very  much  on  the  amount  of  curvature  of  the 
blade.  If  this  be  decided,  a  firmer  hold  of  the  head  is  taken  and 
greater  tractile  force  is  obtained,  out  the  difficulty  of  introduction  is 
increased. 

When  employed  in  the  former  way,  the  fulcrum  is  intended  to  be 
the  hand  of  the  operator ;  but  the  risk  of  using  the  maternal  structures 
as  a  point  d'appui,  and  the  inevitable  danger  of  contusion  and  lacera- 
tion which  must  follow,  constitute  one  of  the  chief  objections  to  the 
operation.  Its  value  as  a  tractor  must  always  be  limited  and  quite 


520 


OBSTETRIC    OPERATIONS. 


inferior  to  that  of  the  forceps,  while  it  is  as  difficult  to  introduce  and 
manipulate. 

Cases  in  which  it  is  Applicable. — The  vectis  has  been  recom- 
mended in  cases  in  which  the  low  forceps  operation  is  suitable,  pro- 
vided the  pains  have  not  entirely  ctased.  There  is  no  doubt  that  it 
may  be  quite  capable  of  overcoming  a  slight  impediment  to  the  passage 
of  the  head.  It  is  applied  over  various  parts  of  the  head,  most  com- 
monly over  the  occiput,  in  the  same  manner,  and  with  the  same 
precautions,  as  one  blade  of  the  forceps.  Dr.  Ramsbotham  says  :  "  We 
shall  find  it  necessary  to  apply  it  to  different  parts  of  the  cranium,  and 
perhaps  the  face  also,  successively,  in  order  to  relieve  the  head  from 
its  fixed  condition  and  favor  its  descent."  Such  an  operation  ob- 
viously requires  quite  as  much  dexterity  as  the  application  of  the 
forceps ;  while,  if  we  bear  in. mind  its  comparatively  slight  power  and 
the  risk  of  injury  to  the  maternal  structures,  we  must  admit  that  the 
disuse  of  the  instrument  in  modern  practice  is  amply  justified. 


FIG.  186. 


FIG.  185. 


Vectis  with  hinged  handle. 


Wilmot's  fillet. 


The  vectis  may,  however,  find  a  useful  application  when,  employed 
to  rectify  malpositions,  especially  in  certain  occipito-posterior  presenta- 
tions. This  action  of  the  instrument  has  already  been  considered  (page 
334),  and,  under  such  circumstances,  it  may  prove  of  service  where  the 
forceps  is  inapplicable.  When  so  employed  it  is  passed  carefully  over 
the  occiput,  and,  while  the  maternal  structures  are  guarded  from  injury, 
downward  traction  is  made  during  the  continuance  of  a  pain.  So 
used,  its  application  is  perfectly  simple  and  free  from  danger,  and  for 
this  purpose  it  may  be  retained  as  part  of  the  obstetric  armamen- 
tarium. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.       521 

The  Fillet  is  the  oldest  of  obstetric  instruments,  having  been  fre- 
quently employed  before  the  invention  of  the  forceps,  and  even  in  the 
time  of  Smellie  it  was  much  used  in  the  metropolis.  It  has  since  com- 
pletely fallen  out  of  favor  as  a  scientific  instrument,  although  its  use  is 
every  now  and  again  advocated,  and  it  is  certainly  a  favorite  instru- 
ment with  some  practitioners.  This  is  to  be  explained  by  the  apparent 
simplicity  of  the  operation,  and  the  fact  that  it  can  generally  be  per- 
formed without  the  knowledge  of  the  patient.  The  latter,  however,  is 
one  strong  reason  why  it  should  not  be  used. 

Nature  of  the  Instrument. — The  fillet  consists,  in  its  most  im- 
proved form  (that  which  is  recommended  by  Dr.  Eardley  Wilmot1) 
(Fig.  186),  of  a  slip  of  whalebone  fixed  into  a  handle  composed  of 
two  separate  halves  which  join  into  one.  The  whalebone  loop  is 
slipped  over  either  the  occiput  or  face,  and  traction  used  at  the 
handle.  [2] 

When  applied  over  the  face,  after  the  head  has  rotated,  it  would 
probably  do  no  harm ;  but  if  it  were  so  placed  when  the  head  was 
high  in  the  pelvis,  traction  would  necessarily  produce  extension  of  the 
chin  before  the  proper  time,  and  would  thus  interfere  with  the  natural 
mechanism  of  delivery.  If  placed  over  the  occiput,  it  is  impossible 
to  make  traction  in  the  direction  of  the  pelvic  axes,  as  the  instrument 
will  then  infallibly  slip.  If  traction  be  made  in  any  other  direction, 
there  must  be  a  risk  of  injuring  the  maternal  structures,  or  of  changing 
the  position  of  the  head.  Hence  there  is  every  reason  for  discarding 
the  fillet  as  a  tractor,  or  as  a  substitute  for  the  forceps,  even  in  the 
simplest  cases. 

It  is  quite  possible  that  it  may  find  a  useful  application  in  certain 
cases  in  which  the  vectis  may  also  be  used,  viz.,  as  a  rectifier  of  mal- 
position ;  and,  from  the  comparative  facility  of  its  introduction,  it 
would  probably  be  the  preferable  instrument  of  the  two. 


CHAPTER   V. 

OPERATIONS  INVOLVING  DESTRUCTION  OF  THE  FCETUS. 

Operations  involving-  the  destruction  and  mutilation  of  the 
child  were  among  the  first  practised  in  midwifery.  Craniotomy  was 
evidently  known  in  the  time  of  Hippocrates,  as  he  mentions  a  mode 
of  extracting  the  head  by  means  of  hooks.  Celsus  describes  a  similar 
operation,  and  was  acquainted  with  the  manner  of  extracting  the  foetus 
in  transverse  presentations  by  decapitation.  Similar  procedures  were 

1  Obst.  Trans.,  1874,  vol.  xv.  p.  172 

[2  The  whalebone  fillet  originated  with  the  Japanese,  and  was  a  fearfully  destructive  instrument 
with  them,  traction  being  made  with  a  windlass.— ED.] 


522  OBSTETRIC    OPERATIONS. 

also  practised  and  described  by  Aetius  and  others  among  the  ancient 
writers.  The  physicians  of  the  Arabian  school  not  only  employed 
perforators  for  opening  the  head,  but  were  acquainted  with  instru- 
ments for  compressing  and  extracting  it. 

Religious  Objections  to  Craniotomy. — Until  the  end  of  the  seven- 
teenth century  this  class  of  operation  was  not  considered  justifiable  in 
the  case  of  living  children  ;  it  then  came  to  be  discussed  whether  the 
life  of  the  child  might  not  be  sacrificed  to  save  that  of  the  mother. 
It  was  authoritatively  ruled  by  the  Theological  Faculty  of  Paris  that 
the  destruction  of  the  child  in  any  case  was  mortal  sin.  "  Si  1'on  ne 
pent  tirer  Fenfant  sans  le  tuer,  on  ne  pent  sans  peche  mortel  le  tirer." 
This  dictum  of  the  Roman  Church  had  great  influence  on  Continental 
midwifery,  more  especially  in  France,  where,  up  to  a  recent  date,  the 
leading  obstetricians  considered  craniotomy  to  be  only  justifiable  when 
the  death  of  the  foetus  had  been  positively  ascertained.  Even  at  the 
present  day  there  are  not  wanting  practitioners  who,  in  their  praise- 
worthy  objection  to  the  destruction  of  a  living  child,  counsel  delay 
until  the  child  has  died — a  practice  thoroughly  illogical,  and  only 
sparing  the  operator's  feelings  at  the  cost  of  greatly  increased  risk  to 
the  mother.  In  England  the  safety  of  the  child  has  always  been  con- 
sidered subservient  to  that  of  the  mother ;  and  it  has  been  admitted 
that,  in  every  case  in  which  the  extraction  of  a  living  foetus  by  any 
of  the  ordinary  means  is  impossible,  its  mutilation  is  perfectly  justi- 
fiable. 

Formerly  Performed  •with  Unjustifiable  Frequency. — It  must  be 
admitted  that  the  frequency  with  which  craniotomy  has  been  performed 
in  England  constitutes  a  great  blot  on  British  midwifery.  During 
the  mastership  of  Dr.  Labbat,  at  the  Rotunda  Hospital,  the  forceps 
was  never  once  applied  in  21,867  labors.  Even  in  the  time  of  Clarke 
and  Collins,  when  its  frequency  was  much  diminished,  craniotomy  was 
performed  three  or  four  times  as  often  as  forceps  delivery.  These  figures 
indicate  a  destruction  of  foetal  life  which  we  cannot  look  back  to  without 
a  shudder,  and  which,  it  is  to  be  feared,  justify  the  reproaches  which 
our  Continental  brethren  have  cast  upon  our  practice.  Fortunately, 
professional  opinion  has  now  completely  recognized  the  sacred  duty  of 
saving  the  infant's  life  whenever  it  is  practicable  to  do  so ;  and  British 
obstetricians  now  teach  as  carefully  as  those  of  any  other  nation  the 
imperative  necessity  of  using  every  endeavor  to  avoid  the  destruction 
of  the  foetus. 

Divisions  of  the  Subject. — The  operation  now  under  consideration 
may  be  necessary :  1st,  when  the  head  requires  either  to  be  simply 
perforated,  or  afterward  more  completely  broken  up  and  extracted — 
an  operation  which  has  received  various  names,  but  is  generally  known 
in  England  as  craniotomy,  and  which  may  or  may  not  require  to  be 
followed  by  further  diminution  of  the  trunk ;  2d,  when  the  arm  pre- 
sents, and  turning  is  impossible.  This  necessitates  one  of  two  pro- 
cedures— decapitation,  with  the  separate  extraction  of  the  body  and 
head,  or  evisceration.  In  both  classes  of  cases  similar  instruments  are 
employed,  and  those  generally  in  use  at  the  present  time  may  be  first 
briefly  described. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    F(ETUS.      523 

Instruments  Employed. —  The  object  of  the  perforator  is  to  pierce 
the  skull  of  the  child,  so  as  to  admit  of  the  brain  being  broken  up 
and  the  consequent  collapse  and  diminution  in  size  of  the  cranium. 
The  perforator  invented  by  Den  man,  or  some  modification  of  it,  has 
been  principally  employed.  It  requires  the  handles  to  be  separated  in 
order  to  open  the  blades,  and  this  cannot  be  done  by  the  operator  him- 
self. This  difficulty  is  overcome  in  the  modification  of  Naegele's 
perforator  used  in  Edinburgh,  in  which  the  handles  are  so  constructed 
that  they  open  the  points  when  pressed  together,  and  are  separated  by 
a  steel  rod  with  a  joint  at  its  centre  to  prevent  their  opening  too 
soon.  By  this  arrangement  the  instrument  can  be  manipulated  by  one 
hand  only.  The  sharp-pointed  portion  has  an  external  cutting  edge, 
with  projecting  shoulders  at  its  base  to  prevent  its  penetrating  too  far 


FIG.  187- 


FIG.  188. 


Various  forms  of  perforators. 


into  the  cranium.  Many  modifications  of  these  arrangements  have 
since  been  contrived  (Figs.  187,  188,  189).  In  some  parts  of  the 
Continent  a  perforator  is  used  constructed  on  the  principle  of  the 
trephine;  but  this  is  vastly  more  difficult  to  work  and  has  the  great 
disadvantage  of  simply  boring  a  hole  in  the  skull,  instead  of  splitting 
it  up,  as  is  done  by  the  sharp-pointed  instrument. 

The  instruments  for  extraction  are  the  crotchet  and  craniotomy 
forceps. 

Crochets  and.  Craniotomy  Forceps. — The  crotchet  is  a  sharp- 
pointed  hook  of  highly  tempered  steel,  which  can  be  fixed  on  some 
portion  of  the  skull,  either  internal  or  external,  traction  being  made 
by  the  handle.  The  shank  of  the  instrument  is  either  straight  or 
curved  (Figs.  190  and  191),  the  latter  being  preferable,  and  it  is  either 
attached  to  a  wooden  handle  or  forged  in  a  single  piece  of  metal.  A 
modification  of  this  instrument  is  known  as  Oldham's  vertebral  hook. 
It  consists  of  a  slender  hook,  measuring  with  its  handle  thirteen 


524 


OBSTETRIC    OPERATIONS. 


inches  in  length,  which  is  passed  through  the  foramen  magnum  and 
fixed  in  the  vertebral  canal,  so  as  to  secure  a  firm  hold  for  traction. 
All  forms  of  crotchets  are  open  to  the  serious  objection  of  being  liable 
to  slip,  or  break  through  the  bone  to  which  they 
FIGS.  190,  i9i.  are  fixed,  so  wounding  either  the  soft  parts  of  the 

mother,  or  the  fingers  of  the  operator  placed  as  a 
guard.  Hence  they  are  discountenanced  by  most 
recent  writers,  and  may  with  propriety  be  regarded 
as  obsolete  instruments. 

Their  place  as  tractors  is  well  supplied  by  the 
more  modern  craniotomy  forceps  (Fig.  192).  These 
are  intended  to  lay  -hold  of  the  skull,  one  blade 
being  introduced  within  the  cranium,  the  other  ex- 
ternally, and,  when  a  firm  grasp  has  been  obtained, 
downward  traction  is  made.  A  second  object  it 
fulfils  is  to  break  away  and  remove  portions  of  the 
skull  when  perforation  and  traction  alone  are  insuffi- 
cient to  effect  delivery.  Many  forms  of  craniotomy 
forceps  are  in  use — some  armed  with  formidable 
teeth;  others,  of  simpler  construction,  depending 
on  their  roughened  and  serrated  internal  surfaces 
for  firmness  of  grasp.  For  general  use,  there  is 
no  better  instrument  than  the  cranioclast  of  Sir 
James  Y.  Simpson  (Fig.  193),  which  admirably 
fulfils  both  these  indications.  It  consists  of  two 
separate  blades  fastened  by  a  button  joint.  The 
extremities  of  the  blades  are  of  a  duck-billed  shape, 
and  are  sufficiently  curved  to  allow  of  a  firm  grasp 
of  the  skull  being  taken  :  the  upper  blade  is  deeply 
grooved  to  allow  the  lower  to  sink  into  it,  and  this  gives  the  instru- 
ment great  power  in  fracturing  the  cranial  bones,  when  that  is  found 
to  be  necessary.  It  need  not,  however,  be  employed  for  the  latter 
purpose ;  and  the  blades,  being  serrated  on  their  under  surface,  form 
as  perfect  a  pair  of  craniotomy  forceps  as  any  in  ordinary  use.  Pro- 
vided with  it,  we  are  spared  the  necessity  of  procuring  a  number  of 
instruments  for  extraction. 

Cephalotribe. — Amongst  modern  improvements  in  midwifery  there 
are  few  which  have  led  to  more  discussion  than  the  use  of  the  cephalo- 
tribe. This  instrument,  originally  invented  by  Baudelocque,  was  long 
employed  on  the  Continent  before  it  was  used  in  England,  the  preju- 
dice against  it  being  no  doubt  due  to  its  formidable  size  and  appear- 
ance. [r]  Of  late  years  many  of  our  leading  obstetricians  have  used 
it  in  preference  to  either  the  crotchet  or  craniotomy  forceps,  and  have 
materially  modified  and  improved  its  construction,  so  that  the  most  ob- 
jectionable features  of  the  older  instruments  are  now  entirely  removed. 
The  cephalotribe  consists  of  two  powerful  solid  blades,  which  are 
applied  to  the  head  after  perforation,  and  approximated  by  means  of  a 
screw  so  as  to  crush  the  cranial  bones,  and  after  this  it  may  also  be 


Crotchets. 


It  was  introduced  into  our  country  in  1843,  under  the  name  of  brise-ttte. — ED.] 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.       525 

used  for  extraction.  The  peculiar  value  of  the  instrument  is  that, 
when  properly  applied,  it  crushes  the  firm  base  of  the  skull,  which  is 
left  untouched  by  craniotomy;  or,  if  it  does  not,  it  at  least  causes  the 
base  to  turn  edgewise  within  the  blades,  so  as  to  be  in  a  more  favorable 
position  for  extraction.  Another  and  specially  valuable  property  is 
that  it  crushes  the  bones  within  the  scalp,  which  forms  a  most  efficient 
protective  covering  to  their  sharp  edges.  In  this  way  one  of  the 
principal  dangers  of  craniotomy — the  wounding  of  the  maternal  pas- 
sages by  spiculae  of  bone — is  entirely  avoided. 

FIG.  192.  FIG.  193. 


Craniotomy  forceps.  Simpson's  cranioclast. 


The  cephalotribe,  therefore,  acts  in  two  ways — as  a  crusher  and  as 
a  tractor.  Some  obstetricians  believe  the  former  to  be  its  more  im- 
portant use,  and  even  maintain  that  the  cephalotribe  is  unsuited  for 
traction.  This  view  is  specially  maintained  by  Pajot,  who  teaches 
that,  after  the  size  of  the  skull  has  been  diminished  by  repeated 
crushings,  its  expulsion-  should  be  left  to  the  natural  powers.  There 
are  some  grounds  for  believing  that  in  the  greater  degrees  of  obstruc- 
tion the  tractile  power  of  the  instrument  should  not  be  called  into  use ; 
but,  in  the  large  majority  of  cases,  the  facility  with  which  the  crushed 
head  may  be  withdrawn  by  it  constitutes  one  of  its  chief  claims  to  the 
attention  of  the  obstetrician.  No  one  who  has  used  it  in  this  way, 
and  experienced  the  rapid  and  easy  manner  in  which  it  accomplishes 
delivery,  can  have  any  doubt  on  this  point. 

There  is  every  reason  to  believe  that  cephalotripsy  will  be  much 
extended  in  Great  Britain,  and  that  it  will  be  considered,  as  I  believe 
it  unquestionably  deserves  to  be,  the  ordinary  operation  in  cases  re- 
quiring destruction  of  the  fcetus.[']  The  comparative  merits  of  cephalo- 
tripsy and  craniotomy  will  be  subsequently  considered. 

f1  This  is  certainly  not  its  future  in  the  United  States,  where  foetal  destruction  is  being  avoided, 
under  the  largely  diminished  fatality  of  the  Ctesarean  section  and  symphyseotomy. — ED.] 


526 


OBSTETRIC    OPERATIONS. 


FIG.  194. 


The  most  perfect  cephalotribe  is  probably  that  known  as  Braxton 
Hicks's  (Fig.  194),  which  is  a  modification  of  Simpson's.  It  is  not 

of  unwieldy  size,  but  sufficiently  pow- 
erful for  any  case,  and  not  extravagant 
in  price.  The  blades  have  a  slight 
pelvic  curve,  which  materially  facili- 
tates their  introduction,  yet  not  suffi- 
ciently marked  to  interfere  with  their 
being  slightly  rotated  after  application. 
Dr.  Kidd,  of  Dublin,  prefers  a  straight 
blade;  while  Dr.  Matthews  Duncan 
thought  it  better  to  use  a  somewhat 
bulkier  instrument,  modelled  on  the 
type  of  the  Continental  cephalotribes. 
The  principle  of  action  of  all  these  is 
identical,  and  their  differences  are  not 
of  very  material  importance. 

Section  of  the  Skull  by  the  For- 
ceps-saw, or  Ecraseur.  —  Another 
mode  of  diminishing  the  fcetal  skull 
is  by  removing  it  in  sections.  The 
object  is  aimed  at  in  the  forceps-saw 
of  Van  Huevel,  which  consists  of  two 
large  blades,  not  unlike  those  of  the 
cephalotribe  in  appearance.  Within 
these  there  is  a  complicated  mechanism, 
working  a  chain-saw  from  below  up- 
ward, which  cuts  through  the  foetal 
skull ;  the  separated  portions  are  sub- 
sequently withdrawn  piecemeal.  This 
instrument  is  highly  spoken  of  by  the 
Belgian  obstetricians,  who  believe  that 
it  affords  by  far  the  safest  and  most 
effectual  way  of  reducing  the  bulk  of  the  foetal  skull.  A  somewhat 
similar  instrument  has  been  invented  by  Tarnier.  In  Great  Britain 
these  instruments  are  practically  unknown  ;  and,  although  they  must 
be  admitted  to  be  theoretically  excellent,  the  complexity  and  cost  of 
the  apparatus  have  always  stood  in  the  way  of  their  being  used. 

Dr.  Barnes  has  suggested  that  the  same  results  may  be  obtained  by 
dividing  the  head  with  a  strong  wire  ecraseur.  So  far  as  I  know,  this 
suggestion  has  never  yet  been  carried  out  in  practice,  not  even  by 
himself,  and  therefore  it  is  not  possible  to  say  much  about  it.  I 
should  imagine,  however,  that  there  would  be  considerable  difficulty 
in  satisfactorily  passing  the  loop  of  wire  over  the  skull  in  a  pelvis  in 
which  there  is  any  well-marked  deformity. 

Cases  requiring  Craniotomy. — The  most  common  cause  for  which 
craniotoniy  or  cephalotripsy  is  performed  is  a  want  of  proper  propor- 
tion between  the  head  and  the  maternal  passages.  This  may  arise 
from  a  variety  of  causes.  The  most  important,  and  that  most  often 
necessitating  the  operation,  is  osseous  deformity.  This  may  exist 


Hicks's  cephalotribe. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.      527 

either  in  the  brim,  cavity,  or  outlet,  and  it  is  most  often  met  with  in 
the  autero-posterior  diameter  of  the  brim.  Obstetric  authorities  differ 
considerably  as  to  the  precise  amount  of  contraction  which  will  pre- 
vent the  passage  of  a  living  child  at  term.  Thus  Clarke  and  Burns 
believe  that  a  living  child  cannot  pass  through  a  pelvis  in  which  the 
antero-posterior  diameter  at  the  brim  is  less  than  three  and  one-quarter 
inches.  Ramsbotham  fixes  the  limit  at  three  inches,  and  Osborne  and 
Hamilton  at  two  and  three-quarters  inches.  The  latter  is  the  extreme 
limit  at  which  the  birth  of  a  living  child  is  possible ;  but  there  can 
be  no  doubt  that,  under  favorable  circumstances,  it  may  be  possible  to 
draw  the  foetus,  after  turning,  through  a  pelvis  of  that  size.  The 
opposite  limit  of  the  operation  is  still  more  open  to  discussion.  Various 
authorities  have  considered  it  quite  possible  to  draw  a  mutilated  foetus 
through  a  pelvis  in  which  the  antero-posterior  diameter  does  not  exceed 
one  and  one-half  inch,  and,  indeed,  have  succeeded  in  doing  so.  But 
then  there  must  be  a  fair  amount  of  space  in  the  transverse  diameter 
of  the  pelvis  to  admit  of  the  necessary  manipulations.  If  there  be  a 
clear  space  here  of  three  inches  and  upward,  it  is  no  doubt  possible  to 
deliver  per  vias  naturales;  but  in  such  extreme  deformities,  the  diffi- 
culties are  so  great,  and  the  bruising  of  the  maternal  structures  so 
extensive,  that  it  becomes  an  operation  of  the  greatest  possible  severity, 
with  results  nearly  as  unfavorable  to  the  mother  as  the  Caesarean 
section. [']  Hence  some  Continental  authorities  have  not  scrupled  to 
prefer  the  latter  operation  in  the  worst  forms  of  pelvic  deformity.  The 
rule  in  English  practice  always  has  been  that  craniotomy  must  be  per- 
formed whenever  it  is  practicable ;  and  there  can  be  no  doubt  that  it 
is,  generally  speaking,  the  right  one. 

Between  from  two  and  three-quarters  to  three  inches  antero-posterior 
diameter  in  the  one  direction,  and  one  and  three-quarters  inches  in  the 
other,  may  be  said  to  be  the  limits  of  craniotomy,  provided,  in  the 
latter  case,  there  be  a  fair  amount  of  space  in  the  transverse  diameter. 
The  same  limits  may  be  laid  down  with  regard  to  tumors  or  other 
sources  of  obstruction. 

There  are  a  few  other  conditions  in  which  craniotomy  is  justifiable, 
independently  of  pelvic  contraction,  such  as  certain  conditions  of  the 
soft  parts  which  are  supposed  to  render  the  passage  of  the  head  pecu- 
liarly dangerous  to  the  mother.  Among  them  may  be  mentioned 
swelling  and  inflammation  of  the  vagina  from  the  length  of  the  pre- 
vious labor,  bauds  and  cicatrices  of  the  vagina,  and  occlusion  and 
rigidity  of  the  os.  It  is  hardly  too  much  to  say  that  with  a  proper 
use  of  the  resources  of  midwifery,  the  destruction  of  a  living  foetus 
for  any  of  these  conditions  might  be  obviated.  The  most  common  of 
them  is  undoubtedly  swelling  of  the  soft  parts  causing  impaction  of 
the  head,  an  occurrence  which  ought  to  be  invariably  prevented  by 
a  timely  use  of  the  forceps.  Should  interference  unfortunately  be 
delayed  until  impaction  has  actually  taken  place,  doubtless  no  other 
resource  but  craniotomy  would  be  left ;  but  such  cases,  it  is  to  be 
hoped,  are  now  of  rare  occurrence  in  British  practice.  Undue  rigidity 

t1  The  experience  of  our  country  indicates  that  in  extreme  pelvic  deformity  the  conservative 
Caesarean  section  has  the  less  risk  of  the  two.— ED.] 


OBSTETRIC    OPERATIONS. 

of  the  os  can  be  overcome  by  dilatation  with  the  caoutchouc  bags,  or* 
in  more  serious  cases,  by  incision,  which  would  certainly  be  less 
perilous  to  the  mother  than  dragging  even  a  mutilated  foetus  through 
the  small  and  rigid  aperture.  In  the  case  of  bands  and  cicatrices  in 
the  vagina,  dilatation  or  incision  will  generally  suffice  to  remove  the 
obstruction  ;  but  even  were  this  not  so  here,  as  in  excessive  rigidity  of 
the  perineum,  it  would  be  better  that  slight  lacerations  should  take 
place  than  that  the  child  should  be  killed. 

Certain  complications  of  labor  are  held  to  justify  craniotomy, 
such  as  rupture  of  the  uterus,  convulsions,  and  hemorrhage.  The 
application  of  the  forceps  or  turning  will  generally  answer  our  purpose 
equally  well,  especially  as  we  have  the  means  of  dilating  the  os  suffi- 
ciently to  admit  of  one  or  other  of  them  being  performed  when  the 
natural  dilatation  is  not  sufficient.  Craniotomy  in  rupture  of  the 
uterus  will  also  be  rarely  indicated,  as  we  have  seen  that  coeliotomy 
appears  to  afford  a  better  chance  to  the  mother  in  those  cases  in 
which  the  foetus  has  partially  or  entirely  escaped  from  the  uterine 
cavity. 

Want  of  proportion  between  the  foetus  and  the  pelvis,  depending  on 
undue  size  of  the  head,  either  natural  or  the  result  of  disease,  may 
render  the  operation  essential.  In  the  former  of  these  cases  we  shall 
generally  have  first  attempted  delivery  with  the  forceps,  and,  if  it  has 
failed,  there  can  be  no  doubt  as  to  the  propriety  of  lessening  the  bulk 
of  the  head  by  perforation,  unless  we  determine  to  attempt  delivery  by 
symphyseotomy  (see  p.  557). 

In  most  obstetric  works  we  are  recommended  to  perforate  rather 
than  apply  the  forceps,  when  we  are  convinced  that  the  child  has 
ceased  to  live.  This  advice  is  based  on  the  greater  facility  with  which 
craniotomy  can  be  performed,  and  its  supposed  greater  safety  to  the 
mother.  There  can  be  no  doubt  of  the  ease  with  which  the  child  can 
be  extracted  after  perforation,  when  the  pelvis  is  not  contracted  ;  and, 
if  we  could  always  be  sure  of  our  diagnosis,  the  rule  might  be  a  good 
one.  Before  acting  on  it,  however,  we  must  bear  in  mind  the  extreme 
difficulty  of  positively  ascertaining  the  death  of  the  foetus.  Of  the 
signs  usually  relied  on  for  this  purpose,  there  are  scarcely  any  which 
are  not  open  to  fallacy,  except  peeling  of  the  scalp,  and  disintegration 
of  the  cranial  bones,  which  do  not  take  place  unless  the  child  has  been 
dead  for  a  length  of  time,  and  are,  therefore,  useless  in  most  instances. 
Discharge  of  the  meconium  constantly  takes  place  when  the  child  is 
alive ;  a  cold  and  pulseless  prolapsed  cord  may  belong  to  a  twin ;  and 
a  foetal  heart  may  become  temporarily  inaudible,  although  the  child  is 
not  dead.  If,  indeed,  we  have  carefully  watched  the  foetal  heart  all 
through  the  labor,  and  heard  it  become  more  and  more  feeble,  and 
finally  stop  altogether,  we  might  be  certain  that  the  child  has  died ; 
but  surely  such  observations  would  rather  indicate  an  early  recourse 
to  the  forceps  or  version,  so  as  to  obviate  the  fatal  result  we  know  to 
be  impending. 

Perforation  of  the  After-coming-  Head. — In  certain  breech  pres- 
entations, or  after  turning,  it  may  be  found  impossible  to  extract  the 
head  without  diminishing  its  size  by  perforating  behind  the  ear.  In 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.      529 
i 

such  cases  we  know  to  a  certainty  whether  the  child  be  alive  or  dead 
before  resorting  to  the  operation. 

The  preliminary  step,  whether  we  resort  to  cephalotripsy  or  crani- 
otomy,  is  perforation,  which  will,  therefore,  be  first  described.  In  the 
former-  the  desirability  of  first  perforating  the  head  is  not  always 
recognized.  To  endeavor  to  crush  the  nead  without  perforating  is 
needlessly  to  increase  the  difficulties  of  the  case,  and  it  should  be 
remembered,  as  a  cardinal  rule,  that  perforation  is  an  essential  pre- 
liminary to  the  proper  use  of  the  cephalotribe. 


FIG.  195. 


Perforation  of  the  skull. 

Before  perforating  we  must  carefully  ascertain  the  exact  relation  of 
the  os  to  the  presenting  part,  since,  in  many  cases,  the  operation  is 
performed  before  the  os  is  fully  dilated,  when  there  is  a  risk  of  wound- 
ing the  cervix.  Two  or  more  fingers  of  the  left  hand  should  be  passed 
up  to  the  head  and  placed  against  the  most  prominent  part  of  the 
parietal  bone.  Under  these,  used  as  guard  (Fig.  195),  the  perforator 
should  be  cautiously  introduced  until  the  scalp  is  reached.  It  is  im- 
portant to  fix  on  a  bony  part  of  the  skull,  and  not  on  a  suture  or 
fontanelle,  for  puncture,  because  our  object  is  to  break  up  the  vault  of 
the  cranium  as  much  as  possible,  so  as  to  allow  the  skull  to  collapse. 
When  the  instrument  has  reached  the  point  we  have  selected,  it  should 
be  made  to  penetrate  the  scalp  and  skull  with  a  semi-rotatory  boring 

34 


530  OBSTETRIC    OPERATIONS. 

motion,  and  advanced  until  it  has  sunk  up  to  the  rests,  which  will 
oppose  its  further  progress.  Occasionally  considerable  force  will  be 
necessary  to  effect  penetration,  more  especially  if  the  scalp  be  swollen' 
by  long-continued  pressure ;  and  this  stage  of  the  operation  will  be 
facilitated  by  causing  an  assistant  to  steady  the  head  by  pressure  on 
the  foetus  through  the  abdomen,  more  especially  if  it  be  still  free  above 
the  pelvic  brim.  We  must  then  press  together  the  handles  of  the 
instrument,  which  will  have  the  effect  of  widely  separating  the  cutting 
portion,  and  making  an  incision  through  the  bones.  After  this  the 
point  should  be  turned  around,  and  again  opened  at  right  angles  to 
the  former  incision,  so  as  to  make  a  free  crucial  opening.  During  this 
process  care  must  be  taken  to  bury  the  perforator  in  the  skull  up  to 
the  rests,  so  as  to  avoid  the  possibility  of  injuring  the  maternal  soft 
parts.  The  instrument  should  now  be  introduced  within  the  skull 
and  moved  freely  about,  so  as  to  thoroughly  and  completely  break  up 
the  brain.  Especial  care  must  be  taken  to  reach  the  medulla  oblongata 
and  base  of  the  brain,  for,  if  these  are  not  destroyed,  we  might  subject 
ourselves  to  the  distress  of  extracting  a  child  in  whom  life  was  not 
extinct.  If  this  part  of  the  operation  be  thoroughly  performed,  there 
will  be  no  necessity  for  washing  out  the  brain  by  the  injection  of  warm 
water,  as  is  sometimes  recommended,  for  the  broken-up  tissue  will 
escape  freely  through  the  opening  made  by  the  perforator. 

The  perforation  of  the  after-coming  head  does  not  generally  offer 
any  particular  difficulty.  It  is  accomplished  in  the  same  manner,  the 
child's  body  being  well  drawn  out  of  the  way  by  an  assistant.  The 
point  of  the  perforator,  carefully  guarded  by  the  finger,  is  guided  up 
to  the  occiput,  or  behind  the  ear,  where  it  is  inserted,  or  perforation 
may  be  performed  through  the  hard  palate. 

If  there  be  no  necessity  for  very  rapid  delivery,  and  the  pains  be 
still  present,  it  is  often  advisable  to  wait  ten  minutes  or  a  quarter  of 
an  hour  before  proceeding  to  extract.  This  delay  will  allow  the  skull 
to  collapse  and  become  moulded  to  the  cavity  of  the  pelvis,  when  forced 
down  by  the  pains,  and  possibly  the  natural  efforts  may  suffice  to  finish 
the  labor  in  that  time;  or,  at  least,  the  head  will  have  descended 
further,  and  will  be  in  a  better  position  for  extraction.  Should  per- 
foration be  required  after  having  failed  to  deliver  with  the  forceps — 
and  this  is  only  likely  to  be  the  case  when  the  obstruction  is  com- 
paratively slight — it  is  certainly  a  good  plan  to  perforate  without 
removing  the  forceps,  which  may  then  be  used  as  tractors. 

AVe  have  now  to  decide  on  the  method  of  extraction,  and  our  choice 
generally  lies  between  the  cephalotribe  and  the  craniotomy  forceps, 
although  in  some  few  cases,  in  which  the  pelvic  contraction  is  slight, 
version  may  be  advantageously  employed.  Some  have  even  advised 
version  as  a  preliminary  step  in  all  cases  requiring  craniotomy,  the 
skull  being  perforated  through  the  roof  of  the  mouth,  and  subsequently 
crushed  with  the  cephalotribe.1 

Comparative  Merits  of  Cephalotripsy  and  Craniotomy. — Those 
who  have  used  both  must,  I  think,  admit  that  in  any  ordinary  case,  in 

1  See  Donald  on  "  Methods  of  Craniotomy,"  Obst.  Trans.,  vol.  xxxi.  p.  28. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    F(ETUS.       531 

which  the  obstruction  is  not  great,  and  only  a  comparatively  slight 
diminution  in  the  size  of  the  head  is  required,  cephalotripsy  is  infi- 
nitely the  easier  operation.  The  facility  with  which  the  skull  can  be 
crushed  is  sometimes  remarkable,  and  those  who  will  take  the  trouble 
to  read.the  reports  of  the  operation  published  by  Braxton  Hicks,  Kidd, 
and  others,  cannot  fail  to  be  struck  with  the  rapidity  with  which  the 
broken-down  head  may  often  be  extracted.  This  is  far  from  being  the 
case  with  the  craniotomy  forceps,  even  when  the  obstruction  is  moder- 
ate only;  for  it  may  be  necessary  to  use  considerable  traction,  or  the 
blades  may  take  a  proper  grasp  with  difficulty,  or  it  may  be  essential 
to  break  down  and  remove  a  considerable  portion  of  the  vault  of  the 
cranium  before  the  head  is  lessened  sufficiently  to  pass.  During  the 
latter  process,  however  carefully  performed,  there  is  a  certain  risk  of 
injuring  the  maternal  structures,  and,  in  the  hands  of  'a  nervous  or 
inexperienced  operator,  this  danger,  which  is  entirely  avoided  in  ceph- 
alotripsy, is  far  from  slight.  The  passage  of  the  blades  of  the  cephalo- 
tribe  is  by  no  means  difficult,  and  I  think  it  must  be  admitted  that  the 
possible  risks  attending  it  are  comparatively  small.  On  account,  there- 
fore, of  its  simplicity  and  safety  to  the  maternal  structures,  I  believe 
cephalotripsy  to  be  decidedly  the  preferable  operation  in  all  cases  of 
moderate  obstruction. 

When  we  approach  the  lower  limit,  and  have  to  do  with  a  very 
marked  amount  of  pelvic  deformity,  the  two  operations  stand  on  a 
more  equal  footing.  Then  the  deformity  may  be  so  great  as  to  render 
it  difficult  to  pass  the  blades  of  even  the  smallest  cephalotribe  sufficiently 
deep  to  grasp  the  head  firmly,  and  even  when  they  are  passed,  the  space 
is  often  so  limited  as  to  impede  the  easy  working  of  the  instrument. 
Besides  this,  repeated  crushings  may  be  required  to  diminish  the  skull 
sufficiently.  I  attach  but  little  importance  to  the  argument  that  the 
diminution  of  the  skull  in  one  diameter  increases  its  bulk  in  another. 
The  necessity  of  removing  and  replacing  the  blades  on  another  part  of 
the  skull,  and  of  repeating  this  perhaps  several  times,  in  the  manner 
recommended  by  Pajot,  is  a  far  more  serious  objection.  To  do  this  in 
a  contracted  pelvis  involves,  of  necessity,  the  risk  of  much  contusion. 
Fortunately  cases  of  this  kind  are  of  extreme  rarity,  much  more  so 
than  is  generally  believed,  but  when  they  do  occur  they  tax  the  resources 
of  the  practitioner  to  the  utmost. 

On  the  whole,  the  conclusion  I  would  be  inclined  to  arrive  at  with 
regard  to  the  two  operations  is,  that  in  all  ordinary  cases  cephalo- 
tripsy is  safer  and  easier,  whereas  in  cases  with  considerable  pelvic 
deformity,  the  advantages  of  cephalotripsy  are  not  so  well  marked, 
and  craniotomy  may  even  prove  to  be  preferable. 

The  first  step  in  using  the  cephalotribe  is  the  passage  of  the  blades. 
These  are  to  be  inserted  in  precisely  the  same  manner,  and  with  the 
same  precautions,  as  in  the  high  forceps  operation.  In  many  cases  the 
os  is  not  fully  dilated,  and  it  is  absolutely  essential  to  pass  the  instru- 
ment within  it.  Special  care  should,  therefore,  be  taken  to  avoid  any 
injury  to  its  edges,  and,  for  this  purpose,  two  or  three  fingers  of  the  left 
hand,  or  even  the  whole  hand,  should  be  passed  high  up,  so  as  thoroughly 
to  protect  the  maternal  structures.  In  order  that  the  base  of  the  skull 


532 


OBSTETRIC    OPERATIONS. 


FIG.  196. 


may  be  reached  and  effectually  crushed,  the  blades  must  be  deeply 
inserted,  and,  in  doing  this,  great  care  and  gentleness  must  be  used.  As 
the  projecting  promontory  of  the  sacrum  generally  tilts  the  head  for- 
ward, the  handles  of  the  instrument,  after  locking,  must  be  well  pressed 
backward  toward  the  perineum.  If  the  blades  do  not  lock  easily,  or 
if  any  obstruction  to  their  passage  be  experienced,  one  of  them  must 
be  withdrawn  and  reintroduced,  just  as  in  a  forceps  operation.  Care 
must  be  taken,  as  the  instrument  is  being  inserted,  to  fix  and  steady 
the  head  by  abdominal  pressure,  since  it  is  generally  far  above  the 
brim  and  would  readily  recede  if  this  precaution  were  neglected. 
When  the  blades  are  in  situ,  we  proceed  to  crush  by  turning  the  screw 
slowly,  and  as  the  blades  are  approximated  the  bones  yield  and  the 
cephalotribe  sinks  into  the  cranium.  The  crushed  portion  then  meas- 
ures, of  course,  no  more  than  the  thickness  of  the  blades,  that  is,  about 
one  and  one-half  inches.  This  is  necessarily  accompanied  by  some 
bulging  of  the  part  of  the  cranium  that  is  not  within  the  grasp  of  the 

instrument  (Fig.  196),  but  in  slight  de- 
formity this  is  of  no  consequence  and  we 
may  proceed  to  extraction,  waiting,  if  pos- 
sible, for  a  pain,  and  drawing  at  first  down- 
ward in  the  axis  of  the  pelvic  inlet,  as  in 
forceps  delivery,  then  in  the  axis  of  the 
outlet.  The  site  of  perforation  should  be 
examined  to  see  that  no  spiculae  of  bone  are 
projecting  from  it,  and  if  so  they  should 
be  carefully  removed.  In  such  cases  the 
head  often  descends  at  once,  and  with  the 
greatest  ease.  Should  it  not  do  so,  or 
should  the  obstruction  be  considerable,  a 
quarter  turn  should  be  given  to  the  handles 
of  the  instrument,  so  as  to  bring  the  crushed 
portion  into  the  narrower  diameter  and 
the  uncrushed  portion  into  the  wider  trans- 
verse diameter.  It  may  now  be  advisable 
to  remove  the  blades  carefully,  and  to  re- 
introduce  them  with  the  same  precautions 
so  as  to  crush  the  unbroken  portion  of  the 
skull.  This  adds  materially  to  the  diffi- 
culties of  the  case,  since  the  blades  have  a 
tendency  to  fall  into  the  deep  channel 
already  made  in  the  cranium,  and  so  it  is 
by  no  means  always  easy  to  seize  the  skull 
in  a  new  direction.  Before  reapplying 
them,  if  the  condition  of  the  patient  be 

Fcetal  head  crushed  by  the  g°°d  ?nd    PalnS  be   P^Sent,  it  may  be  Well 

cephalotribe.  to  wait  an  hour  or  more,  in  the  hope  of  the 

head  being  moulded  and  pushed  down  into 

the  pelvic  cavity.  This  was  the  plan  adopted  by  Dubois,  and,  accord- 
ing to  Tarnier,  was  the  secret  of  his  great  success  in  the  operation. 
Pajot's  method  of  repeated  crushings,  in  the  greater  degrees  of  contrac- 


197. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FOETUS.       533 

tion,  is  based  on  the  same  idea,  and  he  recommends  that  the  instrument 
should  be  introduced  at  intervals  of  two,  three,  or  four  hours,  accord- 
ing to  the  state  of  the  patient,  until  the  head  is  thoroughly  crushed ; 
no  attempts  at  traction  being  used,  and  expulsion  being  left  to  the 
natural  powers.  This,  he  says,  should  always  be  done  when  the  con- 
traction is  below  two  and  one-half  inches,  and  he  maintains  that  it  is 
quite  possible  to  effect  delivery  by  this  means  when  there  is  only  one 
and  one-half  inches  in  the  antero-posterior  diameter.  The  repeated 
introduction  of  the  blades  in  this  fashion  must  necessarily  be  hazard- 
ous, except  in  the  hands  of  a  very  skilful  operator ;  and  I  believe  that 
if  a  second  application  fail  to  overcome  the  difficulty,  which  will  only 
be  very  exceptionally  the  case,  it  would  be  better  to  resort  to  the  meas- 
ures presently  to  be  described. 

Prof.  Alex.  R.  Simpson,  of  Edinburgh,1  has  suggested  the  use  of  an 
instrument  which  he  calls  a  "  basilyst."  Its  object  is  to  break  up  the 
base  of  the  foetal  skull  from  within,  after  the  method 
originally  proposed  by  Guyon.  The  screw-like  portion 
of  the  instrument  (Fig.  197),  which  is  inserted  through 
the  perforation  made  in  the  cranial  vault,  is  driven 
through  the  hard  base,  which  is  then  disintegrated  by 
the  separate  movable  blade.  If  experience  proves  that 
this  instrument  can  be  readily  worked,  it  promises  to  be 
a  valuable  addition  to  our  armamentarium,  since  it  will 
effectually  destroy  the  most  resistant  portion  of  the  skull, 
without  risk  of  injury  to  the  maternal  structures,  and 
thus  very  materially  facilitate  extraction. 

Extraction  by  the  Craniotomy  Forceps. — Should 
we  elect  to  trust  to  the  craniotomy  forceps  for  extraction, 
one  blade  is  to  be  introduced  through  the  perforation,  and 
the  other,  placed  in  opposition  to  it,  on  the  outside  of  the 
scalp.  In  moderate  deformities,  traction  applied  during 
the  pains  may  of  itself  suffice  to  bring  down  the  head. 
Should  the  obstruction  be  too  great  to  admit  of  this,  it  is 
necessary  to  break  down  and  remove  the  vault  of  the  Prof  A  R  simp_ 
cranium.  For  this  purpose  Simpson's  cranioclast  answers  son's  basilyst. 
better  than  any  other  instrument.  One  of  the  blades  is 
passed  within  the  cranium,  the  other,  if  possible,  between  the  scalp 
and  the  skull,  and  the  portion  of  bone  grasped  between  them  is  broken; 
off;  this  can  generally  be  accomplished  by  a  twisting  motion  of  the 
wrist,  without  using  much  force.  The  separated  portion  of  bone  is 
then  extracted,  the  greatest  care  being  taken  to  guard  the  maternal 
structures,  during  its  removal,  by  the  fingers  of  the  left  hand.  The 
instrument  is  then  applied  to  a  fresh  part  of  the  skull,  and  the  same 
process  repeated  until  as  much  of  the  vault  of  the  cranium  as  may  be 
necessary  is  broken  up  and  removed. 

Dr.  Braxton  Hicks2  has  conclusively  shown  that  in  difficult  cases, 
after  the  removal  of  the  cranial  vault,  the  proper  procedure  is  to  bring 
down  the  face,  since  the  smallest  measurement  of  the  skull  after  the 


*  Edin.  Med.  Journ.,  vol.  1879-80,  p.  865. 


*  Obst.  Trans.,  1867,  vol.  vii.  p.  57. 


534 


OBSTETRIC    OPERATIONS. 


removal  of  the  upper  part  of  the  cranium  is  from  the  orbital  ridge  to 
the  alveolar  edge  of  the  superior  maxillary  bone.  This  alteration  in 
the  presentation  he  proposes  to  effect  by  a  small  blunt  hook  made 
for  the  purpose,  which  is  forced  into  the  orbit,  by  means  of  which  the 
face  is  made  to  descend.  Barnes  recommends  that  this  should  be  done 
by  fixing  the  craniotomy  forceps  over  the  forehead  and  face,  and 
making  traction  in  a  backward  direction,  so  as  to  get  the  face  past  the 
projecting  promontory  of  the  sacrum.  The  importance  of  bringing 
down  the  face  was  long  ago  pointed  out  by  Burns,  but  it  had  been  lost 
sight  of  until  Hicks  again  drew  attention  to  it  in  the  paper  referred 
to.  In  the  class  of  cases  in  which  this  procedure  is  valuable,  the  risk 
to  the  maternal  passages,  from  the  removal  of  the  fractured  portions 
of  bone,  must  always  be  considerable,  and  it  is  of  great  importance 
not  only  to  preserve  the  scalp  as  entire  as  possible,  so  as  to  protect 
them,  but  to  use  the  utmost  possible  care  in  removing  the  broken 
pieces  of  bone. 

Extraction  of  the  Body. — When  the  extraction  of  the  head  has 
been  effected,  either  by  the  cephalotribe  or  the  craniotomy  forceps, 
there  is  seldom  much  difficulty  with  the  body.  By  traction  on  the 
head  one  of  the  axillae  can  easily  be  brought  within  reach,  and  if  the 
body  does  not  readily  pass,  the  blunt  hook  should  be  introduced  and 
traction  made  until  the  shoulder  is  delivered.  The  same  can  then  be 
done  with  the  other  arm.  If  there  be  still  difficulty,  the  cephalotribe 
may  be  used  to  crush  the  thorax.  The  body  is,  however,  so  com- 
pressible that  this  is  rarely  required. 


[FlG.  198. 


[FlG.  190. 


Straight  craniotomy  forceps.] 


Curved  craniotomy  forceps.] 


[The  craniotomy  forceps  chiefly  in  use  with  us  were  devised  by  the 
late  Prof.  Charles  D.  Meigs  for  his  second  operation  upon  Mrs.  Rey- 
bold,  of  Philadelphia,  in  1833,  and  have  been  used  repeatedly  since, 
either  as  tractors  or  for  reducing  the  size  of  the  foetal  head,  in  cases  of 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.       535 

deformity  of  the  pelvis.1  Some  obstetricians  prefer  the  less  curved 
and  broader-bladed  instrument  of  Great  Britain  as  a  tractor ;  but  for 
the  general  purposes  of  picking  away  the  cranial  bones  and  drawing 
clown  the  base  of  the  skull  in  cases  of  extreme  pelvic  deformity  there 
is  no  more  simple  appliance  than  that  of  Dr.  Meigs. 

To  act  upon  an  oval  body  like  the  foetal  head,  Dr.  M.  was  obliged  to 
prepare  two  forms  of  forceps — straight  and  curved— to  be  used  as 
might  be  required  according  to  the  part  of  the  skull  to  be  broken  down 
or  drawn  upon.  These  are  lightly  made,  serrated,  and  twelve  and  a 
half  inches  in  length. — ED.] 

Embryotomy. — There  only  remains  for  us  to  consider  the  second 
class  of  destructive  operations.  These  may  be  necessary  in  long- 
neglected  cases  of  arm  presentation,  in  which  turning  is  found  to  be 
impracticable.  Here,  fortunately,  the  question  of  killing  the  foetus 
does  not  arise,  since  it  will,  almost  necessarily,  have  already  perished 
from  the  continuous  pressure.  We  have  two  operations  to  select  from, 
decapitation  and  evisceration.  [And  a  third,  the  improved  Csesareaii 
section. — ED.] 

The  former  of  these  is  an  operation  of  great  antiquity,  having  been 
fully  described  by  Celsus.  It  consists  in  severing  the  neck,  so  as  to 
separate  the  head  from  the  body;  the  body  is  then  withdrawn  by 
means  of  the  protruded  arm,  leaving  the  head  in  utero  to  be  subse- 
quently dealt  with.  If  the  neck  can  be  reached,  without  great  difficulty 
— and,  in  the  majority  of  cases,  the  shoulder  is  sufficiently  pressed  down 
into  the  pelvis  to  render  this  quite  possible — there  can  be  no  doubt  that 
it  is  much  the  simpler  and  safer  operation. 

The  whole  question  rests  on  the  possibility  of  dividing  the  neck. 
For  this  purpose  many  instruments  have  been  invented.  The  one 
generally  recommended  in  this  country  is  known  as  Ramsbotham's 
hook,  and  consists  of  a  sharply  curved  hook  with  an  internal  cutting 
edge.  This  is  guided  over  the  neck,  Avhich  is  divided  by  a  sawing 
motion.  There  is  often  considerable  difficulty  in  placing  the  instru- 
ment over  the  neck,  although,  if  this  were  done,  it  would  doubtless 
answer  well.  Others  have  invented  instruments,  based  on  the  principle 
of  the  apparatus  for  plugging  the  nostrils,  by  means  of  which  a  spring 
is  passed  round  the  neck,  and  to  the  extremity  of  the  spring  a  short 
cord,  or  the  chain  of  an  ecraseur,  is  attached ;  the  spring  is  then  with- 
drawn and  brings  the  chain  or  cord  into  position.  The  objection  to 
any  of  these  apparatus  is,  that  they  are  unlikely  to  be  at  hand  when 
required,  for  few  practitioners  provide  themselves  with  costly  instru- 
ments which  they  may  never  require.  It  is  of  importance,  therefore, 
that  we  should  have  at  our  command  some  means  of  dividing  the  neck 
which  are  available  in  the  absence  of  any  of  these  contrivances. 
Dubois  recommended  for  this  purpose  a  strong  pair  of  blunt  scissors. 
The  neck  is  brought  as  low  as  possible  by  traction  on  the  prolapsed 
arm,  and  the  blades  of  the  scissors  guided  carefully  up  to  it.  ^  By  a 
series  of  cautious  snipping  movements  it  is  then  completely  divided 
from  below  upward.  This,  if  the  neck  be  readily  within  reach,  can 

P  The  illustrations  given  are  tafcen  from  the  instruments  devised  by  Dr.  Meigs  as  an  improve- 
ment upon  his  original  pattern,  and  will  be  seen  to  differ  from  those  usually  presented  In  American 
obstetrical  publications.— ED.] 


536  OBSTETRIC    OPERATIONS. 

generally  be  effected  without  any  particular  difficulty.  Dr.  Kidd,  of 
Dublin,1  who  strongly  advocated  this  operation,  recommended  that  an 
ordinary  male  elastic  catheter,  strongly  curved  and  mounted  on  a  firm 
stilet,  or,  still  better,  on  a  uterine  sound,  should  be  passed  round  the 
neck.  Previous  to  introduction  a  cord  should  be  passed  through  the 
eye  of  the  catheter,  which  is  left  round  the  neck  when  it  is  withdrawn. 
By  means  of  this  cord  a  strong  piece  of  whipcord,  or  the  wire  of  an 
e'craseur,  can  easily  be  drawn  round  the  neck  and  used  for  dividing  it. 
The  former,  to  protect  the  maternal  structures,  may  be  worked  through 
a  speculum,  and  by  a  series  of  lateral  movements  the  neck  is  easily 
severed.  The  e'craseur,  however,  offers  special  advantage,  since  it 
entirely  does  away  with  any  risk  of  injuring  the  mother. 

Withdrawal  of  the  Body  and  Delivery  of  the  Head. — After  the 
neck  is  divided  the  remainder  of  the  operation  is  easy.  The  body  is 
withdrawn  without  difficulty  by  the  arm,  and  we  then  proceed  to 
deliver  the  head.  By  abdominal  pressure,  this,  in  most  cases,  can  be 
pushed  down  into  the  pelvis,  so  as  to  come  easily  within  reach  of  the 
cephalotribe,  which  is  by  far  the  best  instrument  for  extraction.  Pre- 
liminary perforation  is  not  necessary,  since  the  brain  can  escape  through 
the  severed  vertebral  canal.  The  secret  of  doing  this  easily  is  to  fix 
and  press  down  the  head  sufficiently  from  above,  otherwise  it  would 
slip  away  from  the  grasp  of  the  instrument.  The  perforator  and 
craniotomy  forceps  may  be  used,  if  the  cephalotribe  be  not  at  hand. 
Perforation  is,  however,  by  no  means  always  easy,  on  account  of  the 
mobility  of  the  head.  After  it  is  accomplished,  one  blade  of  the 
craniotomy  forceps  is  passed  within  the  skull,  the  other  externally,  and 
the  head  slowly  drawn  down. 

Evisceration. — The  alternative  operation  of  evisceration  is  a  much 
more  troublesome  and  tedious  procedure,  and  should  only  be  used  when 
the  neck  is  inaccessible.  The  first  step  is  to  perforate  the  thorax  at  its 
most  depending  part,  and  to  make  as  wide  an  opening  into  it  as  pos- 
sible, in  order  to  gain  access  to  its  contents.  Through  this  the  thoracic 
viscera  are  removed  piecemeal,  being  first  broken  up  as  much  as  possible 
by  the  perforator,  and  then,  the  diaphragm  being  penetrated,  those  in 
the  abdomen.  The  object  is  to  allow  the  body  to  collapse  and  the 
pelvic  extremities  to  descend,  as  in  spontaneous  evolution.  This  can 
be  much  facilitated  by  dividing  the  spinal  column  with  a  strong  pair 
of  scissors  introduced  into  the  opening  made  in  the  thorax,  so  that  the 
body  may  be  doubled  up  as  on  a  hinge.  Here  the  crotchet  may  find  a 
useful  application,  for  it  can  be  passed  through  the  abdominal  cavity 
and  fixed  on  some  point  in  the  interior  of  the  child's  pelvis,  and  thus 
strong  traction  can  be  made  without  any  risk  of-  injury  to  the  mother. 
It  can  be  readily  understood  that  this  process  is  so  lengthy  and  difficult 
as  to  render  it  probably  the  most  trying  of  obstetric  operations  ;  it  is 
certainly  inferior  in  every  respect  to  decapitation,  and  is  only  to  be 
resorted  to  when  that  is  impracticable.2 

1  Dublin  Quart.  Journ.  of  Med.  Science,  1871,  vol.  li.  p.  3%"!. 

*  In  nine  cases  of  impaction  of  the  foetus  in  a  transverse  position,  in  the  United  States,  the 
Csesarean  operation  has  been  performed,  owing  to  great  difficulty  in  accomplishing  either  decapi- 
tation or  evisceration,  and  six  of  the  women  were  saved.  The  three  deaths  were  from  exhaustion. 
—Harris's  note  to  third  American  edition. 


C^ESAREAN    SECTION.  637 


CHAPTER   YI. 

THE  C2ESAREAN  SECTION— PORRO-CJE3AREAN  OPERATION. 

History  of  the  Ceesarean.  Section. — The  Csesarean  section  lias 
perhaps  given  rise  to  more  discussion  than  any  other  subject  connected 
with  midwifery,  and  there  is  yet  much  difference  of  opinion  as  to  the 
limits  of,  and  indications  for,  the  operation.  The  period  at  which  the 
Csesarean  section  was  first  resorted  to  is  not  known  with  accuracy.  It 
seems  to  have  been  practised  by  the  Greeks,  after  the  death  of  the 
mother ;  and  Pliny  mentions  that  Scipio  Africanus  and  Manlius  were 
born  in  this  way.  The  name  of  Csesar  is  said  to  have  been  given  to 
children  so  extracted,  and  afterward  to  have  been  assumed  as  a  family 
patronymic.  These  children  were  dedicated  to  Apollo,  whence  arose 
the  practice  of  things  sacred  to  that  god  being  taken  under  the  special 
protection  of  the  family  of  the  Caesars.  Many  celebrities  have  been 
supposed  to  owe  their  lives  to  the  operation,  among  the  rest  .^Escula- 
pius,  Julius  Csesar,  and  Edward  VI.  of  England.  Regarding  the  two 
latter,  there  is  conclusive  proof  that  the  tradition  is  without  foundation. 
There  is  no  doubt  that  the  operation  was  constantly  practised  on 
women  who  had  died  at  an  advanced  period  of  pregnancy,  and  indeed 
it  has,  at  various  times,  been  enforced  by  law.  Thus,  among  the 
Romans  it  was  decreed  by  Nurna  that  no  pregnant  woman  should  be 
buried  until  the  foetus  had  been  removed  by  abdominal  section.  The 
Italian  laws  also  made  it  necessary,  and  the  operation  has  ahvays 
received  the  strong  support  of  the  Roman  Church.  So  lately  as  the 
middle  of  the  eighteenth  century,  the  King  of  Sicily  sentenced  to  death 
a  physician  who  had  neglected  to  practise  it.  The  first  authentic  case 
in  which  the  operation  was  performed  on  a  living  wromau  occurred  in 
1491.  It  was  afterward  practised  by  Nufer  in  1500[1]  ;  and  in  1581 
Rousset  published  a  work  on  the  subject  in  wrhich  a  number  of  suc- 
cessful cases  were  related.  In  English  works  of  that  time  it  is  not 
alluded  to,  although  it  was  undoubtedly  performed  on  the  Continent, 
and  to  such  an  extent  that  its  abuse  became  almost  proverbial.  We 
have  evidence  in  Shakespeare,  however,  that  the  operation  was  famil- 
iarly known  in  Great  Britain,  since  he  tells  us  that — 

.    .    .    Macduff  was  from  his  mother's  womb 
Untimely  ripped. 

[This  is  much  more  likely  to  refer  to  a  horn-rip,  as  the  original 
expression,  "ripped  out/'  would  indicate.  Fourteen  such  operations 
under  the  horn-thrusts  of  the  bull,  ox,  cow,  bison,  and  buffalo  have  been 
recorded,  and  ten  women  with  seven  children  escaped  death.  Mrs, 

[i  1498.— ED.] 


538  OBSTETRIC    OPERATIONS. 

Macduff  was  probably  operated  upon  by  a  cow. — ED.]  Pare  and 
Goillemeau,  amongst  the  writers  of  the  period,  were  noted  for  their 
hostility  to  the  operation,  while  others  equally  strongly  upheld  it. 

In  England  it  has,  until  recently,  scarcely  ever  been  performed  in  a 
manner  which  oifers  even  the  faintest  hope  of  success.  It  has  been 
looked  upon  as  almost  necessarily  fatal  to  the  mother,  and  it  has, 
therefore,  been  delayed  until  the  patient  has  arrived  at  the  utmost 
stage  of  exhaustion.  For  example,  in  looking  over  the  records  of 
British  cases,  it  is  no  uncommon  thing  to  find  that  the  Csesarean  sec- 
tion was  resorted  to,  two,  three,  or  even  six  days  after  labor  had  begun, 
and  when  the  patient  was  almost  moribund.  With  rare  exceptions 
[up  to]  within  the  last  few  years,  the  operation  has  been  performed 
[in  England]  in  what  may  be  called  a  hap-hazard  way.  In  many 
cases  long  and  fruitless  attempts  at  delivery  by  craniotomy  had 
already  been  made,  so  that  the  passages  had  been  subjected  to  much 
contusion  and  violence.  Little  or  no  attempt  has  been  made  to  obviate 
the  well-known  risks  of  abdominal  operations ;  no  care  has  been  taken 
to  prevent  blood  and  other  fluids  finding  their  way  into  the  peritoneal 
cavity,  and  no  means  have  been  adopted  subsequently  to  remove  them. 
It  is,  therefore,  not  so  much  a  matter  of  surprise  that  the  mortality 
has  been  so  great,  but  rather  that  any  cases  have  recovered. 

From  what  we  know  of  the  history  of  ovariotomy,  its  early  fatality, 
and  the  extreme  and  even  apparently  exaggerated  precautions  which 
are  essential  to  its  success,  it  is  fair  to  conclude  that,  if  the  Csesarean 
section  were  performed,  as  it  is  to  be  hoped  it  always  will  be  in  future, 
with  the  same  careful  attention  to  minute  details  as  ovariotomy,  the 
results  would  not  be  so  disastrous.  Making  every  allowance  for  these 
facts,  it  must  be  admitted  that  the  Casarean  section,  as  hitherto  per- 
formed, has  been  necessarily  almost  a  forlorn  hope ;  although  happily 
recent  statistics  show  that  this  need  no  longer  be  considered  the  case. 
In  making  these  observations  I  have  no  intention  of  contesting  the 
well-established  rule  of  British  practice  that  it  is  not  admissible  as  an 
operation  of  election,  and  must  only  be  resorted  to  when  delivery  per 
vias  naturales  is  impossible. 

Statistical  Returns  are  not  Reliable. — The  mortality,  as  given  in 
statistical  returns  from  various  sources,  differs  so  greatly  as  to  make 
them  but  little  reliable.  Radford  has  tabulated  the  operations  per- 
formed in  England  up  to  1879,  and  the  list  has  been  completed  by 
Harris  up  to  1889.  The  cases  amount  to  154  in  all,  of  which  32  were 
successful.  Michaelis  and  Kayser  [1833  and  1841]  found  that  out  of 
258  cases  and  338  operations,  54  and  64  percent,  respectively  were  fatal. 
These  include  operations  performed  under  all  sorts  of  conditions,  even 
when  the  patient  was  almost  moribund;  and  until  we  are  in  possession 
of  a  sufficient  number  of  cases  performed  under  conditions  showing 
that  the  result  is  certainly  due  to  the  operation — in  which  it  was  under- 
taken at  an  early  period  of  labor  and  performed  with  a  reasonable 
amount  of  care — it  is  obviously  impossible  to  arrive  at  any  reliable 
conclusions  as  to  the  mortality  of  the  operation.  That  it  is  necessarily 
hopeless  is  certainly  not  the  case,  and  we  know  that  on  the  Continent, 
where  it  is  resorted  to  much  oftener  and  earlier  in  labor  than  in  Eng- 


C^ESAREAN    SECTION.  539 

laud,  there  are  authentic  cases  in  which  it  has  been  performed  twice, 
thrice,  and  even,  in  one  instance,  four  times  on  the  same  patient. 
Kayser  [1841]  thought  that  a  second  operation  on  the  same  patient 
afforded  a  better  prognosis  than  a  first,  probably  because  peritoneal 
adhesions,  resulting  from  the  first  operation,  have  shut  off  the  general 
abdominal  cavity  from  the  Titerine  wound ;  and  he  believed  that  in 
second  operations  the  mortality  is  not  more  than  29  per  cent. 

The  Caesarean  Section  in  America. — The  Csesareaii  section  [thus 
far]  has  been  more  successful  in  America  than  in  Great  Britain.  Dr. 
Harris,  of  Philadelphia,  who  has  paid  much  attention  to  the  subject, 
has  collected  234  cases  occurring  in  the  United  States,  of  which  105, 
or  over  44  per  cent.j  were  successful  as  regards  the  mother^1]  These 
favorable,  results  he  refers  partly  to  the  fact  that  none  of  the  American 
cases  were  the  subjects  of  mollities  ossium,  rhachitic  patients  forming 
one-half  of  the  entire  number.  He  also  gives  some  interesting  facts 
showing  how  remarkably  the  mortality  of  the  operation  was  lessened 
under  the  old  method,  when  performed  soon,  and  the  patient  wras  not 
exhausted  by  long  and  fruitless  labor.  Out  of  28  selected  cases  of  this 
kind,  21,  or  75  per  cent.,  were  successful.  The  latest  European  statis- 
tics show  that  the  modifications  of  the  operation  now  universally 
adopted  upon  the  Continent  of  Europe  are  followed  by  the  most  grati- 
fying results.  [Of  54  women  operated  upon  in  Leipzig,  51  recovered ; 
34  were  saved  out  of  38  in  Dresden;  16  were  delivered  under  the 
section  in  the  Krankenhaus  of  Vienna,  in  order,  without  a  death,  and 
Dr.  Murdoch  Cameron,  of  Glasgow,  has  only  lost  3  out  of  30.  Here 
we  have  a  record  of  138  cases  with  128  recoveries,  a  mortality  of  7£ 
percent.,  showing  the  possibilities  of  this  method  of  delivery  in  well- 
appointed  maternities,  and  under  competent  operators.  In  view  of 
these  facts,  we  are  inclined  in  our  country  to  estimate  the  danger  of 
the  operation  according  thereto. — ED.] 

Results  to  the  Child. — The  mortality  of  the  children  likewise  can- 
not be  ascertained  from  statistical  returns,  since,  in  the  large  majority 
of  cases  in  which  dead  children  were  extracted,  the  result  had  nothing 
to  do  with  the  operation.  Indeed,  there  is  nothing  in  the  operation 
itself  which  can  reasonably  be  supposed  to  affect  the  child.  If,  there- 
fore, the  child  be  alive  when  the  operation  is  commenced,  there  is 
every  probability  of  its  being  extracted  alive  ;  and  Radford's  conclu- 
sion, that  "  the  risks  to  infants  in  Caesarean  births  is  not  much  greater 
than  that  which  is  contingent  on  natural  labor,  provided  correct  prin- 
ciples of  practice  are  adopted,"  probably  very  nearly  represents  the 
truth. 

Causes  Requiring1  the  Operation. — The  Cassarean  section  is  re- 
quired when  there  is  such  defective  proportion  between  the  child  and 
the  maternal  passages  that  even  a  mutilated  foetus  cannot  be  extracted. 
Tliis  in  by  far  the  greatest  number  of  cases  is  due  to  deformity  of  the 
pelvis  arising  from  rickets  or  mollities  ossium.  The  latter  may  occur 
in  a  patient  who  has  been  previously  healthy,  and  who  has  given  birth 
to  living  children.  It  is  a  more  common  cause  of  the  extreme  varieties 

P  By  the  old  method,  146,  with  90  deaths-and  by  the  new,  79,  with  29  deaths.    2  died  out  of 
the  last  20.— ED.] 


540  OBSTETRIC    OPERATIONS. 

of  deformity  than  rickets;  and  out  of  132  British  cases  tabulated  by 
Radford,  in  56  the  deformity  was  produced  by  osteomalacia,  and  in  31 
by  rickets^1]  In  certain  cases  the  pelvis  itself  may  be  of  normal  size, 
but  has  its  cavity  obstructed  by  a  solid  tumor  of  the  ovary,  of  the 
uterus  itself,  or  one  growing  from  the  pelvic  Avail.  The  obstruction 
may  also  depend  on  morbid  conditions  of  the  maternal  soft  parts,  of 
which  the  most  common  is  advanced  malignant  disease  of  the  cervix. 
Other  conditions  may,  however,  render  the  operation  essential.  Thus 
Dr.  Newman2  recorded  a  case  in  which  he  performed  it  for  insurmount- 
able resistance  and  obstruction  of  the  cervix,  which  was  believed  at  the 
time  to  be  caused  by  malignant  disease.  The  patient  recovered,  and 
was  subsequently  delivered  naturally,  and  without  anything  abnormal 
being  made  out,  This  renders  it  probable  that  the  disease  was  not 
malignant,  and  it  may  possibly  have  been  an  extensive  inflammatory 
exudation  into  the  tissues  of  the  cervix,  subsequently  absorbed.  I 
myself  was  present  at  a  Cajsarean  section  performed  in  Calcutta  in  the 
year  1857,  when  the  pelvis  was  so  uniformly  blocked  up  with  exuda- 
tion, probably  due  to  extensive  pelvic  cellulitis  or  htematocele,  that  the 
operation  was  essential. 

Limits  of  Obstruction  Justifying  the  Operation.  —  Different 
accoucheurs  have  fixed  on  various  limits  for  the  operation.  Most 
British  authorities  are  of  opinion  that  it  need  not  be  resorted  to  if  the 
smallest  diameter  of  the  pelvis  exceed  one  and  a  half  inches.3  This 
question  has  already  been  considered  in  discussing  craniotomy,  and  it 
has  been  shown  that  a  mutilated  fretus  may  be  drawn  through  a  pelvis 
of  one  and  a  half  inches  ante ro-posterior  diameter,  provided  there  be  a 
space  of  three  inches  in  the  transverse  diameter.  If  sufficient  space  for 
using  the  necessary  instruments  does  not  exist,  the  Caesarean  section 
may  be  required,  even  when  there  is  a  larger  autero-posterior  diameter 
than  one  and  a  half  inches.  This  is  especially  likely  to  occur  when 
we  have  to  do  with  deformity  arising  from  mollities  ossium,  in  which 
the  obstruction  is  in  the  sides  and  outlet  of  the  pelvis,  the  true  con- 
jugate being  sometimes  even  elongated.  On  the  Continent  the  Csesarean 
section  is  constantly  practised  as  an  operation  of  election  when  the 
smallest  diameter  measures  from  two  to  two  and  a  half  inches ;  and 
when  the  child  is  known  to  he  alive,  some  foreign  authors  recommend 
it  when  there  is  as  much  as  three  inches  in  the  antero-posterior  diameter. 
In  Great  Britain,  where  the  life  of  the  child  is  most  properly  con- 
sidered of  secondary  importance  to  the  safety  of  the  mother,  we  cannot 
fix  one  limit  for  the  operation  when  the  child  is  living,  and  another 
when  it  is  dead.  Xor,  I  think,  can  we  admit  the  desire  of  the  mother 
to  run  the  risk,  rather  than  sacrifice  the  child,  as  a  justification  of  the 
operation,  although  this  is  laid  down  as  an  indication  by  Schroeder.* 
Great  as  are  the  dangers  attending  crauiotomy  in  extreme  deformity, 
there  can  be  no  doubt  that  we  must  perform  it  whenever  it  is  prac- 

f1  Observations  on  the  Csesarean  Section,  etc.,  2d  edition,  1880. — ED.] 

&  Obst.  Trans.,  1866,  vol.  vii.  p.  343. 

3  In  Dr.  Parry's  table  of  70  craniotomies,  there  are  34  cases  of  two  to  two  and  a  half  inches  con- 
jugate. [British  authorities  are  changing  their  views  very  materially  in  regard  to  the  applicability 
of  the  Csesarean  section  to  cases  formerly  delivered  by  craniotomy. — ED.] 

*  Manual  of  Midwifery,  p.  202. 


C^ESAREAN    SECTION.  541 

ticable,  and  only  resort  to  the  Csesareau  section  when  no  other  means 
of  delivery  are  possible. ['] 

For  this  reason  I  think  it  unnecessary  to  discuss  the  question 
whether  we  are  justified  in  destroying  the  fetus  in  several  successive 
pregnancies,  when  the  mother  knows  that  it  is  impossible  for  her  to 
give  birth  to  a  living  clyld.  Denman  was  the  first  to  question  the 
advisability  of  repeating  craniotomy  on  the  same  patient.  Amongst 
modern  authors  liadford  took  the  most  decided  view  on  this  point, 
and  distinctly  taught  that  even  when  delivery  by  craniotomy  is 
possible,  it  "  can  be  justified  on  no  principle,  and  is  only  sanctioned 
by  the  dogma  of  the  schools,  or  by  usage,"  and  that,  therefore,  the 
Csesarean  section  should  be  performed  with  the  view  of  saving  the 
child.  Doubtless  much  can  be  said  from  this  point  of  view ;  but, 
nevertheless,  he  would  be  a  bold  man  who  would  deliberately  elect 
to  perform  the  Csesarean  section  on  such  grounds.2  It  is  to  be 
hoped,  however,  that  in  these  days  the  induction  of  premature  labor 
or  abortion  would  always  spare  us  the  necessity  of  deciding  so  delicate 
a  point. 

[One  of  the  vital  questions  of  the  day  is,  "  Shall  the  Csesarean  opera- 
tion be  performed  in  cases  under  relative  indications?"  That  is,  Is  it 
proper  to  elect  to  perform  the  operation  where  the  indications  for  it 
are  not  absolute  and  positive?  If  by  foetal  destruction  the  mother  can 
in  all  probability  be  saved,  is'  it  a  justifiable  act  to  run  a  greater  risk 
in  order  to  save  the  child  ?  Are  the  wishes  of  the  parents  for  a  living 
child  to  be  considered  in  deciding  as  to  the  method  of  delivery  ?  In 
view  of  the  fact  that  a  premature  delivery  cannot  save  the  child  in  a 
given  case,  and  the  mother  has  already  lost  one  or  more  foetuses  by 
craniotomy,  is  it  proper  to  save  the  child  by  an  operation  in  which 
from  6  to  10  per  cent,  of  women  die?  We  think  it  is,  and  should  be 
performed. — ED.] 

Post-mortem  Csesarean  Operation. — The  Csesarean  section  may 
also  be  required  in  cases  in  which  death  has  occurred  during  pregnancy 
or  labor.  This  was  the  indication  for  which  it  was  first  employed,  and 
it  has  constantly  been  performed  when  a  pregnant  woman  has  died  at 
an  advanced  period  of  utero-gestation.  There  is  no  doubt  that  a 
prompt  extraction  of  the  child  under  these  circumstances  has  fre- 
quently been  the  means  of  saving  its  life,  but  by  no  means  so  often  as 
is  generally  supposed.  Thus,  Schwarz3  showed  that  out  of  107  cases 
not  one  living  child  was  extracted.  Duer4  has  written  an  interesting 
paper  on  this  subject,  in  which  he  has  tabulated  55  cases  of  post-mortem 
Csesarean.  sections.  In  40  a  living  child  was  extracted,  the  time  elapsing 
after  the  death  of  the  mother  being  as  follows  •  "  Between  one  and  five 
minutes,  including  ( immediately'  and  '  in  a  few  minutes/  there  were 
21  cases ;  between  five  and  ten  minutes,  none  ;  between  ten  and  fiftee'n 
minutes,  13  cases;  between  fifteen  and  twenty-three  minutes,  2  cases; 

P  This  opinion  is  not  held  in  our  country. — ED  1 

2  This  was  done  twice  successfully  by  Prof.  William  Gibson  in  the  case  of  Mrs.  Reybold,  of 
Philadelphia,  in  1835  and  1837.  after  she  had  twice  bsen  delivered  by  craniotomy  under  Prof.  Charles 
I).  Meigs,  who  declined  destroying  any  more  children  for  her. — Harris's  note  to  third  American 
«dition. 

a  Monats.  f.  Geburt.,  suppl.,  1802,  Bd.  xviii.  S.  112 

*  "Post-mortem  Delivery,"  Amer.  Journ.  of  Obst.,  1879,  vol.  xii:  pp.  1  and  374. 


542  OBSTETRIC    OPERATIONS. 

after  one  hour,  2  cases ;  and  after  two  hours,  2  cases."  In  those  ex- 
tracted, however,  after  the  lapse  of  an  hour,  the  children  did  not  ulti- 
mately survive,  and  the  cases  themselves  seem  open  to  some  doubt. 

"Want  of  Success  in  Post-mortem  Operation. — The  reason  that 
the  want  of  success  has  been  so  great  is  doubtless  the  delay  that  must 
necessarily  occur  before  the  operation  is  resorted  to  ;  for,  independently 
of  the  fact  that  the  practitioner  is  seldom  at  hand  at  the  moment  of 
death,  the  very  time  necessary  to  assure  ourselves  that  life  is  actually 
extinct  will  generally  be  sufficient  to  cause  the  death  of  the  foetus. 
Considering  the  intimate  relations  between  the  mother  and  child,  wo 
can  scarcely  expect  vitality  to  remain  in  the  latter  more  than  a  quarter 
or,  at  the  outside,  half  an  hour  after  it  has  ceased  in  the  former.  The 
recorded  instances  in  which  a  living  child  was  extracted  ten,  twelve, 
and  even  forty  hours  after  death,  were  most  probably  cases  in  which 
the  mother  fell  into  a  prolonged  trance  or  swoon,  during  the  con- 
tinuance of  which  the  child  must  have  been  removed.  A  few  authentic 
cases,  however,  are  known  in  which  there  can  be  no  reasonable  doubt 
that  the  operation  was  performed  successfully  several  hours  after  the 
mother  was  actually  dead. 

Since,  then,  there  is  a  chance,  however  slight,  of  saving  the  child's 
life,  we  are  bound  to  perform  the  operation,  even  when  so  much  time 
has  elapsed  as  to  render  the  chances  of  success  extremely  small.  It 
might  be  considered  almost  superfluous  to  insist  on  the  necessity  of 
assuring  ourselves  of  the  mother's  death  before  commencing  the  neces- 
sary incisions;  but,  unfortunately,  numerous  instances  are  known  in 
which  mistakes  in  diagnosis  have  been  made,  and  in  which  the  first 
steps  of  the  operation  have  shown  that  the  mother  was  still  alive.  The 
operation  should,  therefore,  always  be  performed  with  the  same  care 
and  caution  as  if  the  mother  were  living.  If  death  has  occurred 
during  labor,  some  have  advised  version  as  a  preferable  alternative. 
This  can  only  be  resorted  to,  with  any  hope  of  success,  if  the  passages 
be  in  a  condition  to  admit  of  delivery  with  rapidity ;  otherwise  the 
delay  occasioned  by  dilatation,  even  when  forcibly  accomplished,-  and 
the  drawing  of  the  child  through  the  pelvis,  will  be  almost  necessarily 
fatal.  The  only  argument  in  favor  of  version  is  that  it  is  less  painful 
to  the  friends ;  and  if  they  manifest  a  decided  objection  to  the  Csesarean 
section,  there  can  be  no  reason  why  an  attempt  to  save  the  child  in 
this  way  should  not  be  made. 

Causes  of  Death  after  Caesarean  Section. — The  causes  of  death 
after  the  Caesarean  section  may,  speaking  generally,  be  classed  under 
four  principal  heads :  hemorrhage,  peritonitis  and  metritis,  shock,  sep- 
ticaemia and  exhaustion  from  long.delay.  These  are  pretty  much  the 
same  as  those  following  ovariotomy,  and  the  resemblance  between  the 
two  operations  is  so  great  that  modern  experience  as  to  the  best  mode 
of  performing  ovariotomy,  as  well  as  regards  the  after-treatment, 
may  be  taken  as  a  guide  in  the  management  of  cases  of  Caesarean 
section. 

Hemorrhage  to  an  alarming  extent  is  a  frequent  complication, 
though  seldom  the  cause  of  death.  Thus,  out  of  eighty-eight  opera- 
tions, the  particulars  of  which  have  been  carefully  noted,  severe 


C-SISAREAN    SECTION.  543 

hemorrhage  occurred  in  fourteen,  six  of  which  terminated  successfully, 
and  in  four  only  could  the  fatal  result  be  ascribed  to  the  loss  of  blood. 
In  one  of  these  the  source  of  the  hemorrhage  is  not  mentioned,  in 
another  it  came  from  the  wound  in  the  abdominal  wall,  and  in  the 
other  two  from  the  uterine  incision  being  made  directly  over  the  pla- 
centa. In  neither  of  the  two  latter  was  the  loss  of  blood  immediately 
fatal ;  for  it  was  checked  by  uterine  contraction,  and  only  recurred 
after  many  hours  had  elapsed.  The  divided  uterine  sinuses,  and  the 
open  mouths  of  the  vessels  at  the  placental  site,  are  the  most  common 
sources  of  hemorrhage. 

Much  may  be  done  to  diminish  the  risk  of  bleeding,  but  even  with 
every  precaution  it  must  be  a  source  of  danger.  Hemorrhage  from 
the  abdominal  wall  may  be  best  prevented  by  making  the  incision  as 
nearly  as  possible  in  the  line  of  the  linea  alba,  so  as  not  to  wound  the 
epigastric  arteries,  and  by  controlling  bleeding  by  pressure  forceps  as 
we  proceed,  as  is  done  in  ovariotomy.  The  principal  loss  of  blood 
will.be  met  with  in  dividing  the  uterus  ;  and  this  will  be  the  greatest 
when  the  incision  is  near  or  over  the  placental  site,  where  the  largest 
vessels  are  met  with.  We  are  recommended  to  ascertain  the  position 
of  the  placenta  by  auscultation,  and  thus,  if  possible,  to  avoid  opening 
the  uterus  near  its  insertion.  But  even  if  we  admit  the  placental 
souffle  to  be  a  guide  to  its  situation,  if  the  placenta  be  attached  to  the 
anterior  walls  of  the  uterus,  a  knowledge  of  its  position  would  not 
always  enable  us  to  avoid  opening  the  uterus  in  its  immediate  vicinity. 
We  must,  in  the  event  of  its  lying  under  the  incision,  rather  hope  to 
control  the  hemorrhage  by  removing  it  at  once  from  its  attachments, 
and  rapidly  emptying  the  uterus.  When  the  child  has  been  removed 
there  may  be  a  large  escape  of  blood ;  but  this  will  generally  be  stopped 
by  the  contraction  of  the  uterus,  in  the  same  manner  as  after  natural 
labor.  Should  contraction  not  take  place,  the  uterus  may  be  firmly 
grasped  for  the  purpose  of  exciting  it.  This  plan  was  advocated  by 
the  late  Ludwig  Winckel,  who  had  a  large  experience  in  the  operation ; 
and  by  using  free  compression  in  this  way,  and  making  a  point  of  not 
closing  the  wound  until  the  uterus  was  firmly  contracted,  he  had  never 
met  with  any  inconvenience  from  hemorrhage.  Sanger,  to  whose 
writings  we  owe  so  much  in  perfecting  the  modern  Csesarean  section, 
relies  much  on  frequent  kneading  of  the  uterus  during  the  application 
of  the  sutures.  Murdoch  Cameron,  of  Glasgow,1  who  has  had  the 
largest  experience  of  the  operation  amongst  British  operators,  recom- 
mends that  the  cut  surfaces  of  the  uterus  should  be  firmly  pressed 
together. [2]  He  also  places  a  hard-rubber  oval  pessary  on  the  uterus 
before  commencing  the  incision,  which  is  made  within  the  oval,  and 
by  this  means,  he  says,  the  chance  of  hemorrhage  is  lessened.  If 
bleeding  continue,  styptic  applications  may  be  used,  as  in  a  case 
reported  by  Hicks,  who  was  obliged  to  swab  out  the  uterine  cavity 
with  a  solution  of  perchloride  of  iron.  The  method  first  used  by  Litz- 
mann,  and  adopted  since  by  many  operators,  of  placing  a  soft-rubber 
cord  around  the  cervix,  after  the  uterine  contents  have  been  removed, 

»  British  Med.  Jonrn.,  March  7,  1889. 

[2  Up  to  July  7, 1893,  he  operated  on  30  women,  and  saved  27  of  them.--ED.] 


544  OBSTETRIC    OPERATION'S. 

will  tend  effectually  to  control  hemorrhage,  but  Cameron  objects  to  it 
as  likely  to  induce  inertia  after  its  removal. [J] 

Among  the  most  frequent  causes  of  death  are  peritonitis  and  metritis. 
Kayser  attributed  the  fatal  results  to  them  in  77  out  of  123  unsuccess- 
ful cases. 

The  mere  division  of  the  peritoneum  will  not  account  for  the  fre- 

•quency  of  this  complication,  since  its  occurrence  is  considerably  more 

frequent  than  after  ovariotomy,  in  which  the  injury  to  the  peritoneum 

is  quite  as  great — and  indeed  greater,  if  we  take  into  account  the 

adhesions  which  have  to  be  divided  or  torn  in  that  operation. 

The  division  of  the  uterus  must  be  regarded  as  one  source  of  this 
danger.  Dr.  "West  lays  great  stress  on  its  unfavorable  condition  after 
delivery  for  reparative  action.  He  believes  that  the  process  of  invo- 
lution or  fatty  degeneration  which  commences  in  the  muscular  fibres 
previous  to  delivery,  renders  them  peculiarly  unfitted  to  cicatrize  ;  and 
he  points  out  that,  on  post-mortem  examination,  the  edges  of  the 
incision  have  been  found  dry,  of  unhealthy  color,  gaping,  and  showing 
no  tendency  to  heal.  On  this  account  Hicks  and  others  have  operated 
ten  days  or  more  before  the  full  period  of  labor,  in  the  hope  that  the 
risk  from  this  source  might  be  avoided.  It  is  by  no  means  certain, 
however,  that  the  change  in  the  uterine  fibres  is  the  cause  of  the  wound 
not  healing,  and  involution  will  commence  at  once  when  the  uterus  is 
emptied,  even  if  the  full  period  of  pregnancy  have  not  arrived.  As  a 
point  of  ethics,  moreover,  it  is  questionable  if  we  are  justified  in  antici- 
pating the  date  of  so  dangerous  an  operation,  even  by  a  few  weeks, 
unless  the  benefit  to  be  derived  is  very  decided  indeed. 

One  important  cause  of  peritonitis  is  the  escape  of  the  lochia  through 
the  uterine  incision  into  the  cavity  of  the  peritoneum,  which  there 
decompose  and  act  as  an  unfailing  source  of  irritation.  This  may  be 
prevented,  to  a  great  extent,  by  seeing  that  the  os  uteri  is  patulous,  so 
as  to  afford  a  channel  for  the  escape  of  discharges,  and  by  effective 
closing  of  the  uterine  wound  by  sutures.  In  addition,  there  is  the 
danger  arising  from  blood  and  liquor  amnii  escaping  into  the  peri- 
toneum, and  subsequently  decomposing.  There  is  little  evidence  that 
"  la  toilette  du  peritoine,"  on  which  ovariotomists  now  lay  so  much 
stress,  has  ever  been  particularly  attended  to  in  Ca?sarean  opera- 
tions. [2] 

The  chief  predisposing  cause  of  these  inflammations,  however,  must 
be  looked  for  in  the  condition  of  the  patient,  just  as  asthenic  inflam- 
mation in  ovariotomy  is  most  frequently  met  with  in  those  whose 
general  health  is  broken  down  by  the  long  continuance  of  the  disease. 
We  are  fully  justified,  therefore,  in  assuming  that  peritonitis  and 
metritis  will  be  more  likely  to  occur  after  the  Caesarean  section  when 
that  operation  has  been  unnecessarily  delayed,  and  when  the  patient 
is  exhausted  by  a  protracted  labor.  In  proof  of  this  we  find  that,  in 
a  large  proportion  of  the  cases  above  mentioned,  peritonitis  occurred 
when  the  operation  was  performed  under  unfavorable  conditions. 

P  This  has  so  often  led  to  secondary  hemorrhage  after  its  removal,  that  the  practice  has  been 
generally  condemned  ;  manual  compression  is  mnch  safer.— ED.] 
[2  See  German  and  Austrian  reports  of  operations  performed  within  the  last  ten  years.— ED.] 


CJ3SAREAN    SECTION.  545 

The  sources  of  septicaemia  are  abundantly  evident;  not  the  least, 
probably,  being  absorption  by  the  open  vessels  in  the  uterine  incision. 

The  last  great  danger  is  general  shock  to  the  nervous  system.  In 
Kayser's  123  cases,  30  of  the  deaths  are  referred  to  this  cause.  In 
the  large  majority  of  these  the  patient  was  profoundly  exhausted 
before  the  operation  was  begun.  It  is  in  predisposing  to  these  nervous 
complications  that  we  should,  a  priori,  expect  that  vacillation  and' 
delay  would  be  most  hurtful ;  and  in  operating  when  the  patient's 
strength  is  still  unimpaired,  we  afford  her  the  best  chance  of  bearing 
the  inevitable  shock  of  an  operation  of  such  magnitude. 

In  addition,  a  few  cases  have  been  lost  from  accidental  complications, 
which  are  liable  to  occur  after  any  serious  operation,  and  which  do  not 
necessarily"  depend  on  the  nature  of  the  procedure. 

There  is  only  one  source  of  danger  special  to  the  child  which  is 
worthy  of  attention.  As  the  infant  is  being  removed  from  the  cavity 
of  the  uterus,  the  muscular  parietes  sometimes  contract  with  great 
rapidity  and  force,  so  as  to  seize  and  retain  some  part  of  its  body. 
This  occurred  in  two  of  Dr.  Radford's  cases,  and  in  one  of  them  it  is 
stated  that  "  the  child  was  vigorously  alive  when  first  taken  hold  of, 
but,  from  the  length  of  time  .occupied  in  extracting  the  head,  it  became 
so  enfeebled  as  to  show  only  slight  signs  of  life,"  and  subsequently  all 
attempts  at  resuscitation  failed.  I  have  myself  seen  the  head  caught 
ia  this  way,  and  so  forcibly  retained  that  a  second  incision  was  re- 
quired to  release  it.  In  Dr.  Radford's  cases  the  placenta  happened  to 
be  immediately  under  the  incision,  and  he  attributes  the  inordinate 
and  rapid  contraction  of  the  uterus  to  its  premature  separation.  It  is 
difficult  to  believe  that  this  was  more  than  a  coincidence,  because  the 
contraction  does  not  take  place  until  the  greater  part,of  the  child's 
body  has  been  withdrawn,  and  because  numerous  cases  are  recorded  in 
which  the  uterus  was  opened  directly  over  the  placenta,  or  in  which 
it  was  lying  loose  and  detached,  in  none  of  which  this  accident  occurred. 
The  true  explanation  may,  I  think,  be  found  in  the  varying  irritability 
of  the  uterus  in  different  cases. 

Irrespective  of  the  risk  of  portions  of  the  child  being  caught  and 
detained,  rapid  contraction  is  a  distinct  advantage,  since  the  danger  of 
hemorrhage  is  thereby  thus  diminished.  Serious  consequences  may  be 
best  avoided  by  removing,  when  practicable,  the  head  and  shoulders 
of  the  child  first,  or  by  employing  both  hands  in  extraction,  one  being 
placed  near  the  head,  the  other  seizing  the  feet.'  Either  of  these 
methods  is  preferable  to  the  common  practice  of  laying  hold  of  the 
part  that  may  chance  to  lie  most  conveniently  near  the  line  of  incision. 
If  this  point  were  properly  attended  to,  although  the  detention  of  the 
lower  extremities  might  occasionally  occur,  the  life  of  the  child  would 
not  be  imperilled^1] 

The  Patient  should  be  Prepared  for  the  Operation. — The 
preparation  of  the  patient  for  the  operation  should  seriously  occupy 
the  attention  of  the  practitioner,  and  this  is  the  more  essential  since 
almost  all  patients  requiring  the  Caesarean  section  are  in  a  wretchedly 

fl  Under  the  old  operation  the  foetus  was,  as  a  rule,  extracted  by  the  feet.    Cameron  and  some 
others  now  recommend  to  deliver  by  the  head.— ED. J 


546  OBSTETRIC    OPERATIONS. 

debilitated  condition.  If  the  patient  be  not  seen  until  she  is  actually 
in  labor,  of  course  this  is  out  of  the  question.  But  this  will  rarely  be 
the  case,  since  the  deformed  condition  of  the  patient  must  generally 
have  attracted  attention.  Every  possible  means  should  be  taken, 
therefore,  when  practicable,  to  improve  the  general  health  by  abun- 
dance of  simple  and  nourishing  diet,  plenty  of  fresh  air,  and  suitable 
tonics  (amongst  w Inch  preparations  of  iron  should  occupy  a  prominent 
place),  while  the  state  of  the  secretions,  the  bowels,  skin,  and  kidneys, 
should  be  specially  attended  to.  Whenever  it  is  possible  a  large,  airy 
apartment  should  be  selected  for  the  operation,  which  should  never  be 
done  in  a  hospital,  if  other  arrangements  be  practicable^1  These 
details  may  seem  trivial  and  unnecessary ;  but  to  insure  success  in  so 
hazardous  an  undertaking  no  care  can  be  considered  superfluous,  and 
probably  the  want  of  attention  to  such  points  has  had  much  to  do  with 
increasing  the  mortality. 

The  question  arises  whether  we  should  operate  before  labor  has  com- 
menced. By  selecting  our  own  time,  as  some  have  advised,  we  certainly 
have  the  advantage  of  operating  under  the  most  favorable  conditions, 
instead  of  possibly  hurriedly.  There  are,  however,  numerous  advan- 
tages in  waiting  until  spontaneous  uterine  action  has  commenced,  which 
seem  to  me  to  more  than  counterbalance  the  advantages  of  choosing 
our  own  time.  Prominent  among  these  is  the  partial  opening  of  the 
os  uteri,  so  as  to  afford  a  channel  for  the  escape  of  the  lochia,  and  the 
certainty  of  active  contraction  of  the  uterus,  to  arrest  hemorrhage. 
Barnes  recommends  that  premature  labor  should  be  first  induced,  and 
then  the  operation  performed.  This  seems  to  me  to  introduce  a  need- 
less element  of  complexity ;  and  besides,  in  cases  of  great  deformity  it 
is  by  no  means  always  easy  to  reach  the  cervix  with  the  view  of  bring- 
ing on  labor.  All  needful  arrangements  should  be  made,  so  as  to  avoid 
hurry  and  excitement  when  the  operation  is  commenced,  and  we  may 
then  wait  patiently  until  labor  has  fairly  set  in. 

The  Administration  of  Anaesthetics. — The  operation  itself  is 
simple.  The  patient  should  be  placed  on  a  table,  in  a  good  light,  and 
with  the  temperature  of  the  room  raised  to  about  65°.  Chloroform  has 
so  frequently  been  followed  by  severe  vomiting,  that  it  is  probably 
better  not  to  administer  it.  For  the  same  reason  Sir  Spencer  Wells 
has  long  given  up  using  it  in  ovariotomy,  and  finds  that  chloro-methyl 
answers  admirably ;  ether  also  is  devoid  of  the  disadvantages  of  chloro- 
form. In  one  or  two  cases  local  anaesthesia  has  been  used  by  means  of 
two  spray-producers  acting  simultaneously ;  and  this  plan,  if  the 
patient  have  sufficient  fortitude  to  dispense  with  general  anaesthesia,  has 
the  further  advantage  of  stimulating  the  uterus  to  powerful  contraction. 

To  insure  as  great  a  measure  of  success  as  possible,  the  operation 
should  be  performed  with  all  the  minute  precautions  used  in  ovari- 
otomy. 

Description  of  the  Operation. — The  incision  should  be  made  as  much 
as  possible  in  the  Hue  of  the  linea  alba.  On  account  of  the  deformity, 
the  configuration  of  the  abdomen  is  often  much  altered,  and  some  have 

f1  Modern  operators  prefer  hospital  advantages,  and  the  revolution  in  saving  life  has  "been  mainly 
effected  in  well-ordered  maternities. — ED.] 


C^SAREAN    SECTION.  547 

advised  that  the  incision  should  be  made  oblique  or  transverse,  and  on 
the  most  prominent  part  of  the  abdomen.  [']  The  risk  of  hemor- 
rhage being  thus  much  increased,  the  practice  is  not  to  be  recommended. 
The  incision,  commencing  a  little  above  the  umbilicus,  is  carried  down 
for  about  three  inches  below  it.  The  skin  and  muscular  fibres  are 
carefully  divided,  layer  by  layer,  until  the  shining  surface  of  the  peri- 
toneum is  reached,  and  any  bleeding  vessels  should  be  secured  with 
pressure  forceps  as  we  proceed.  A  small  opening  is  now  made  in  the 
peritoneum,  which  should  be  laid  open  along  the  whole  length  of  the 
incision,  upon  two  fingers  of  the  left  hand  introduced  as  a  guide.  A 
few  silk  sutures,  three  or  four,  should  now  be  passed  through  the  upper 
end  of  the  incision.  The  object  of  these  is  to  temporarily  close  the 
abdominal  parietes  after  the  uterus  is  opened,  so  as  to  prevent  the 
escape  of  the  intestines,  or  the  entrance  of  blood,  etc.,  into  the  perito- 
neal cavity.  Before  incising  the  uterus  an  assistant  should  carefully 
support  it  in  a  proper  position,  and  push  it  forward  by  the  hands 
placed  on  either  side  of  the  incision,  so  as  to  bring  its  surface  into  appo- 
sition with  the  external  wound,  and  prevent  the  escape  of  the  intes- 
tines, and  a  large  flat  sponge  should  be  placed  on  either  side,  between 
the  uterus  and  the  abdominal  parietes,  to  prevent  blood  and  liquor 
amnii  entering  the  abdomen.  If  we  have  reason  to  believe  that  the 
placenta  is  situated  anteriorly,  we  may  incise  the  uterus  on  one  or 
other  side  ;  otherwise  the  line  of  incision  should  be  as  nearly  as  possible 
central.  The  substance  of  the  uterus  is  next  divided  until  the  mem- 
branes are  reached ;  these  are  punctured  and  divided  in  the  same  way 
as  the  peritoneum.  It  is  important  not  to  puncture  these  until  the 
uterine  incision  is  completed,  and  we  are  ready  to  remove  the  child. 
The  uterine  incision  should  be  of  the  same  length  as  that  in  the  abdo- 
men, and  it  should  not  be  made  too  near  the  fundus ;  for  not  only  is 
that  part  more  vascular  than  the  body  of  the  uterus,  but  wounds  in 
that  situation  are  more  apt  to  gape,  and  do  not  cicatrize  so  favorably. 
After  the  uterus  is  opened,  l)r.  Ludwig  AVinckel  has  recommended 
that  the  fingers  of  an  assistant  should  be  placed  in  the  two  terminal 
angles  of  the  wound,  so  that  the  ends  of  the  incision  may  be  hooked 
up  and  brought  into  close  apposition  with  the  abdominal  opening. 
By  this  means  he  prevented  not  only  the  escape  of  blood  and  liquor 
amnii  into  the  cavitv  of  the  peritoneum,  but  also  the  protrusion  of  the 
abdominal  viscera. 

Removal  of  the  Child. — We  now  divide  the  membranes  and  care- 
fully remove  the  child,  the  head  and  shoulders  being  taken  out  (if 
possible)  first ;  the  placenta  and  membranes  are  afterward  extracted. 
Should  the  placenta  be  unfortunately  found  immediately  under  the 
incision,  a  considerable  loss  of  blood  is  likely  to  take  place,  which  can 
only  be  checked  by  removing  it  from  its  attachments  and  concluding 
the  operation  as  rapidly  as  possible. 

Eventration  of  the  Uterus. — As  soon  as  the  child  is  removed,  the 
uterus  should  be  turned  out  of  the  abdominal  cavity,  which  is  tem- 
porarily closed  by  the  sutures  already  introduced,  and  further  protected 
by  placing  a  large  flat  sponge  behind  the  uterus.  At  the  same  time, 

I1  This  was  a  very  old  recommendation  ;  no  one  prefers  it  now. — Ed.] 


518  OBSTETRIC    OPERATIONS. 

hemorrhage  is  controlled  by  a  rubber  cord  tied  round  the  cervix.  [*] 
This  gives  time  thoroughly  to  attend  to  the  suturing  of  the  uterine 
incision,  a  point  of  great  importance.  The  uterus  should  now  be  sur- 
rounded by  soft  napkins  wrung  out  of  warm  1  :  2000  perchloride  of 
mercury  solution.  After  the  placenta  has  been  removed  and  the  hem- 
orrhage arrested  we  should  see  that  the  os  uteri  is  open,  so  that  any 
fluid  ill  the  uterine  cavity  may  drain  into  the  vagina.  The  cavity 
should  also  be  dusted  with  iodoforrn.[2] 

Importance  of  Securing1  Uterine  Contraction. — As  soon  as  the 
child  and  the  secundiues  have  been  extracted,  the  sooner  the  uterus 
contracts  the  better.  It  will  usually  do  so  of  itself,  but  should  it 
remain  lax  and  flabby,  it  should  be  pressed  and  stimulated  by  the  hand. 
We  are  specially  warned  against  handling  the  uterus  by  Rams'ootham 
and  others ;  but  there  seems  no  valid  reason  why  we  should  not  restrain 
hemorrhage  in  this  way,  as  after  a  natural  labor.  The  intervention  of 
the  abdominal  pariotes,  in  their  lax  condition  after  delivery,  can  make 
very  little  difference  between  the  two  cases.  Ergotiue  administered 
hypodermically  will  also  be  useful  in  promoting  efficient  contraction. 

Ligature  of  the  Fallopian  Tubes. — In  some  recent  cases  the  Fallo- 
pian tubes  have  been  ligatured  and  divided  at  the  time  of  the  operation, 
with  the  view  of  preventing  future  impregnation.  This  does  not  sen- 
sibly increase  its  risk,  and  seems  to  be  a  judicious  precaution  in  any 
case  in  which  the  pelvis  is  much  deformed. 

Closure  of  the  Uterine  "Wound. — Much  of  the  recent  success  in 
this  operation  is  due  to  the  careful  closing  of  the  uterine  incision  by 
sutures.  Sanger,  who  has  paid  great  attention  to  this  point,  used  for- 
merly to  strip  off  the  peritoneum  for  about  five  millimetres  on  each 
side  of  the  incision,  and  then  resect  the  muscular  wall  for  about  two 
millimetres  ;  this,  however,  he  has  now  given  up.  He  inserts  eight  to 
ten  deep  sutures  of  silk  through  the  peritoneum  and  muscle,  but  not 
through  the  mucosa,  taking  care  to  turn  in  the  peritoneal  edges  so  as 
to  bring  them  into  accurate  contact,  with  the  view  of  securing  rapid 
adhesion.  The  reason  for.  not  passing  the  sutures  into  the  uterine 
cavity  is  to  prevent  the  possibility  of  septic  material  finding  its  way 
along  the  track  of  the  sutures  into  the  peritoneum.  Finally  he  passes 
twenty  to  twenty-five  fine  silk  sutures  through  the  inverted  edges  of 
the  peritoneum.  Cameron  uses  only  seven  to  twelve  deep  stitches  of 
silk,  and  reserves  superficial,  sutures,  for  which  lie  uses  gut,  for  any 
points  where  it  might  be  thought  advisable  to  insert  them. 

A  point  of  great  importance,  and  not  sufficiently  insisted  on,  is  the 
advisability  of  not  closing  the  abdominal  wound  until  we  are  thor- 
oughly satisfied  that  hemorrhage  is  completely  stopped,  since  any 
escape  of  blood  into  the  peritoneum  would  very  materially  lessen  the 
chances  of  recovery.  In  a  successful  case  reported  by  Dr.  Ne\vman,3 
the  wound  was  not  closed  for  nearly  an  hour.[4]  Before  doing  so,  all 

f1  Recent  experience  prefers  manual  compression,  as  much  safer. — En.] 

[2  This  treatment  has  been  largely  done  away  with.  If  the  child  is  living,  no  internal  applica- 
tion to  the  uterus  is  thought  advisable  by  Cameron  and  other  operators. — ED.] 

a  Obst.  Trans.,  1867,  vol.  yiii.  p.  343. 

[4  Under  the  new  operation,  the  arrest  of  hemorrhage  is  usually  effected  by  the  suturing  of  the 
nterine  .vound.  Twenty-five  years  ago  the  uterus  was  very  rarely  sewed  up  ;  hence  the  precaution 
of  Nuwman.— ED.J 


C'^SAREAN    SECTION.  549 

blood  and  discharges  should  be  carefully  removed  from  the  peritoneal 
cavity  by  clean  soft  sponges  dipped  in  warm  water.  The  abdominal 
wound  should  be  closed  from  above  downward  by  silk  sutures,  which 
should  be  inserted  at  a  distance  of  an  inch  from  each  other  and  passed 
entirely  through  the  abdominal  walls  and  the  peritoneum,  at  some 
little  distance  from  the  edges  of  the  incision,  so  as  to  bring  the  two 
surfaces  of  the  peritoneum  into  contact.  By  this  means  we  insure  the 
closure  of  the  peritoneal  cavity,  the  opposed  surfaces  adhering  with 
great  rapidity.  If,  as  should  be  the  case,  the  operation  is  performed 
with  full  antiseptic  precautions,  the  wound  should  now  be  dressed  pre- 
cisely as  after  ovariotomy. 

Subsequent  Management. — Into  the  subsequent  treatment  it  is 
unnecessary  to  enter  at  any  length,  since  it  must  be  regulated  by  general 
principles,  each  symptom  being  met  as  it  arises.  It  has  been  customary 
to  administer  opiates  freely  after  the  operation  ;  but  they  seem  to  have 
a  tendency  to  produce  sickness  and  vomiting,  arid  ought  not  to  be 
exhibited  unless  pain  or  peritonitis  indicates  that  they  are  required. 
In  fact,  the  treatment  should  in  no  way  differ  from  that  usual  after 
ovariotomy,  and  the  principles  that  should  guide  us  will  be  best  shown 
by  the  following  quotation  from  Sir  Spencer  Wells'  description  of  that 
operation  :  "  The  principles  of  after-treatment  are — to  obtain  extreme 
quiet,  comfortable  warmth,  and  apply  perfectly  clean  linen  to  the  patient; 
to  relieve  pain  by  warm  applications  to  the  abdomen,  and  by  opiate 
enemas ;  to  give  stimulants  when  they  are  called  for  by  failing  pulse 
or  other  signs  of  exhaustion  ;  to  relieve  sickness  by  ice,  or  iced  drinks; 
and  to  allow  plain,  simple,  but  nourishing  food.  The  catheter  must 
be  used  every  six  or  eight  hours,  until  the  patient  can  move  without 
pain.  The  sutures  are  removed  on  the  third  day,[']  unless  tym- 
pauitic  distention  of  the  stomach  or  intestines  endangers  reopening 
of  the  wound.  In  such  circumstances  they  may  be  left  for  some  days 
longer.  The  superficial  sutures  may  remain  until  union  seems  quite 
firm." 

Porro-Caesarean  Operation. — Within  the  last  few  years  an  im- 
portant modification  of  the  Csesarean  section  has  been  adopted,  which 
is  generally  known  as  Porro's  operation,  from  Professor  Porro,  of 
Pa  via,  who  was  the  first  European  surgeon  who  practised  it.  In  this 
operation,  after  the  uterus  is  emptied,  the  entire  organ  is  drawn  out  of 
the  abdominal  wound  and  excised,  its  neck  being  first  constricted  so  as 
to  suppress  hemorrhage,  the  stump  being  fixed  externally  in  the  manner 
of  the  pedicle  in  ovariotomy.  The  idea  is  by  no  means  new.  It 
appears  to  have  been  first  suggested  by  an  Italian — Dr.  Cavallini — in 
1768.  In  1823  the  late  Dr.  Bluudell  made  the  same  proposal,  and 
fortified  it  by  experiments  on  pregnant  rabbits,  in  the  course  of  which 
he  found  that  he  lost  all  by  the  Csesarean  section,  but  saved  three  out 
of  four  in  which  he  ligatured  and  amputated  the  uterus.  The  sug- 
gestion was  not,  however,  carried  into  actual  practice  until  Dr.  Storer, 
of  Boston,  in  1869,  removed  the  uterus  in  a  case  of  fibroid  tumor 
obstructing  the  pelvis  and  impeding  delivery. 

f1  Sutures  after  Cajsarean  section  should  remain  from  seven  to  ten  days;  even  after  eight  days 
the  abdominal  wound  has  been  reopened  by  coughing,  and  death  has  followed.— ED.] 


550  OBSTETRIC    OPERATIONS. 

Since  Porro's  first  case,  the  operation  has  been  frequently  performed 
on  the  Continent,  with  results  which  are,  on  the  whole,  encouraging. 
The  cases  have  been  carefully  tabulated  by  Dr.  Harris,  of  Phila- 
delphia, who  had  collected  up  to  the  end  of  1891,  442  cases  occurring 
in  the  previous  sixteen  years,  with  167  deaths  of  women  and  99  of 
children.  [*]  This  is  an  improvement  on  the  former  figures,  when  the 
mortality  was  50.6  per  cent.2  [This  record  reduces  it  below  40  per 
cent. — ED.]  The  obvious  advantage  of  this  plan  is,  that  instead  of 
leaving  the  incised  uterus,  with  its  possibly  gaping  wound  and  all  the 
attendant  risk  of  septic  mischief,  in  the  abdominal  cavity,  it  is  fixed 
externally,  and  in  a  position  where  it  can  be  readily  dressed. 

The  objection  is  that  it  entirely  unsexes  the  patient;  but  in  the  class 
of  women  requiring  the  Csesarean  section  from  pelvic  deformity,  it  is 
questionable  whether  this  can  be  fairly  considered  as  a  drawback.  It 
is  perhaps  not  justifiable  to  attempt  as  yet  any  positive  decision  as  to 
the  indications  for  this  plan.  It  certainly  seemed  at  first  to  be  less 
dangerous  than  the  Csesarean  section,  but  the  improved  results  recently 
obtained  in  the  latter  operation  have  shown  how  it  aifords  the  patient 
as  good,  if  not  a  better  chance,  without  permanent  mutilation,  and 
Porro's  operation  probably  requires  for  its  skilful  performance  a  more 
extensive  experience  in  abdominal  surgery.  "It  seems  probable, 
therefore,  that  in  future  the  Porro  operation  will  be  chiefly  adopted 
when  for  some  reason,  such  as  the  existence  of  fibro-myomata,  the 
ablation  of  the  uterus  is  specially  indicated." 

The  operation  in  the  successful  cases  has  been  performed  with  full 
antiseptic  precautions,  and  the  neck  of  the  uterus,  after  the  organ  is 
emptied,  carefully  secured  by  ligatures  before  its  body  is  amputated. 
Some  operators  have  encircled  the  neck  of  the  uterus  with  a  chain  or 
wire  ecraseur  before  removing  it,  and  by  this  means  completely  con- 
trolled hemorrhage.  The  late  Dr.  Elliot  Richardson3  transfixed  the 
neck  of  the  uterus  with  two  large  pins  crossing  each  other,  before  re- 
moving the  wire  of  the  Ecraseur,  and  encircled  them  with  stout  carbo- 
lized  cord.  Miiller,  of  Berne,  has  recommended  that  the  entire  uterus 
should  be  turned  out  of  the  abdominal  cavity  through  a  long  incision, 
before  it  is  emptied,  so  as  to  avoid  the  risk  of  its  fluid  contents  entering 
the  abdomen;  but  this  manoeuvre  has  not  always  proved  feasible.  The 
pedicle  has  generally  been  fixed  in  the  lower  angle  of  the  abdominal 
wound  and  dressed  antiseptically.  In  most  cases  one  or  more  drainage- 
tubes  have  been  used,  either  through  Douglas's  space  or  in  the  abdom- 
inal wound. 

Frank*  recommends  a  modification  of  this  operation,  in  which  the 
uterus  is  amputated  through  the  vagina.  After  incising  the  uterus  and 
removing  the  child,  he  inverts  the  uterus  and  applies  an  elastic  liga- 
ture round  it  and  the  ovaries  outside  the  vagina.  He  now  closes  the 
abdominal  wound,  as  in  ovariotomy,  and  subsequently  amputates  the 
uterus  below  the  ligature,  separating  and  sewing  the  peritoneum  over 

P  The  mortality  under  the  last  100  recorded  was  14. — ED.] 

*  See  Godson  on  Porro's  Operation,  Brit.  Med.  Journ.,  1884,  and  note  to  7th  ed.,  vol.  ii.  p.  243. 

*  Amer.  Journ.  of  Med.  Sciences,  1881. 

*  Arch.  f.  Gynak.,  Bd.  xl.  S.  117. 


SECTION.  551 

the  stuinp.  The  operation  is  said  to  be  very  simple,  and  seven  out  of 
the  eight  cases  he  has  thus  operated  on  recovered.1 

[The  Csesarean  Section  of  1893. — It  may  be  of  interest  to  go 
back  fifty  or  sixty  years  and  quote  the  opinions  then  held,  and  esti- 
mates of  mortality  then  made ;  but  it  will  be  much  more  profitable 
to  consider  what  has  been  done  in  the  last  decade,  and  what  is  being 
done  now. 

One  of  the  great  obstacles  to  success  in  the  operation  has  been  a 
fear  to  perform  it,  because  of  its  fatality ;  and  this  dread  of  the  issue 
has  been  a  chief  factor  in  determining  the  measure  of  its  danger. 
British  opinion  has,  until  quite  recently,  had  much  to  do  with  mould- 
ing that  of  our  own  obstetric  surgeons ;  but  thanks  to  recent  successes 
in  America  and  Continental  Europe,  we  are  beginning  to  think  more 
independently,  and  to  look  upon  this  form  of  delivery  with  far  less 
anxiety  and  fear  than  formerly. 

Even  Great  Britain,  through  her  younger  accoucheurs,  has  recently 
shown  signs  of  a  change  of  base,  under  the  influence  of  the  already 
quoted  successes  of  Murdock  Cameron,  which  will  be  much  more 
potent  than  the  still  better  results  in  Leipzig,  Dresden,  and  Vienna, 
because  accomplished  at  home. 

In  our  own  country  we  are  slowly  doing  better,  and  the  work  of  the 
last  three  years  (August,  1890,  to  August,  1893)  shows  a  record  of  28 
cases,  with  four  women  and  four  children  lost.  These  women  died 
after  labors  respectively  of  twelve  days,  seven  days,  three  days ;  and 
one  foetus  was  stillborn;  one  was  delivered  in  a  dying  state;  a  third 
was  of  six  months'  gestation,  but  alive ;  and  the  fourth  lived  two  days. 
Three  of  these  infants  were  the  offspring  of  mothers  who  were  also 
lost. 

One  thing  we  can  be  certain  of,  i.  e.,  that  but  few  women  will  die 
in  this  country  as  a  result  of  the  Csesarean  operation  under  good 
hands,  where  there  is  good  ground  upon  whicli  to  base  a  favorable 
prognosis.  In  the  cases  of  eight  women  where  I  made  this  estimate, 
there  was  not  one  that  terminated  fatally.  In  one,  labor  had  just 
begun ;  in  another  it  had  lasted  a  few  hours,  with  slight  pains ;  in  two, 
it  was  induced;  and  in  four,  it  had  not  commenced.  We  have  opera- 
tors in  New  York,  Philadelphia,  and  Baltimore  who  are  convinced 
that  the  operation,  performed  a  few  days  prior  to  the  time  for  labor  to 
set  in,  has  decided  advantages  over  that  where  the  hour  is  determined 
by  the  commencement  of  parturition.  The  fear  that  the  cervix  may 
not  be  sufficiently  patulous  for  drainage,  or  that  the  uterus  will  not 
properly  contract,  appears  to  be  groundless.  It  must  be  a  very  ex- 

1  It  may  interest  the  reader  to  learn  the  views  of  my  American  editor,  Dr.  Harris,  of  Philadel- 
phia, on  this  subject.  It  is  well  known  that  Dr.  Harris  has  devoted,  an  immense  amount  of  time 
and  labor  to  the  study  of  these  operations,  on  which  he  may  be  taken  to  be  one  of  our  most  reli- 
able authorities.  He  says:  "We  believe  that  the  Porro  operation  will,  In  all  probability,  meet 
with  better  success  than  '  the  conservative,'  in  Great  Britain,  from  the  fact  that  the  last  five  cases 
In  order  have  recovered.  Holding  the  views  there  generally  advocated,  the  section  will  only  be 
made  in  badly  deformed  rhacbitic  dwarfs  and  in  the  subjects  of  malacosteon,  which  are  much  more 
frequently  thus  delivered  than  the  former.  These  will  probably  do  better  under  the  exsective 
method,  which  besides  has  the  advantage  that  it  sometimes  cures  malacosteon,  as  shown  by  the 
results  in  Continental  Europe." — Harris,  note  to  seventh  American  edition. 

[The  remarkable  successes  (1888-1893)  of  Dr.  Murdock  Cameron,  of  Glasgow,  have  set  this  opinion 
aside.  The  Porro  operation  should  be  elected  ia  cases  of  osteomalacia,  as  the  disease  has  been 
arrested  by  it  in  a  number  of  instances.— ED.] 


552  OBSTETRIC    OPERATIONS. 

ceptional  case  where  this  organ  is  not  excited  to  action  by  incising  its 
wall.  We  have  only  to  look  at  the  effect  of  Csesarean  horn-rips,  to 
determine  the  action  of  the  uterus  when  it  is  opened  before  labor. 

What  is  wanted  in  England,  and  especially  in  London,  is  more 
hopefulness  in  the  operation,  and  this  can  only  be  begotten  by  a 
careful  examination  of  the  record  of  the  past  decade.  Let  someone 
collect  the  cases,  and  present  the  causes  of  success  and  failure ;  and  it 
will  soon  be  learned  how  death  is  to  be  avoided.  The  death-rate  in 
London  is  placed  conjecturally  at  50  per  cent.;  but  it  should  be 
known  what  it  is  positively.  If  it  is  as  much  as  one-half,  it  can  cer- 
tainly be  reduced.  Recently  a  rhachitic  primipara  from  Yorkshire,  of 
four  feet  six  inches,  was  operated  upon  in  Philadelphia,  and  is  now 
rapidly  recovering.  We  expected  to  save  her  and  her  child,  and  are 
not  surprised  at  the  result.  If  this  can  be  attained  here,  upon  an 
English  woman,  why  not  in  London  ?  It  should  be  borne  in  mind 
that  a  very  short  labor  is  often  the  key-note  to  a  recovery  and  a  saved 
foetus. 

Sauger,  of  Leipzig,  and  his  followers  in  Germany,  Austria,  and 
America,  have  shown  the  capabilities  of  Caesarean  surgery  where  the 
cases  are  treated  antiseptically  and  the  uterine  wound  closed  by  mul- 
tiple suturing  of  silk.  Ovarian  exsection  has  largely  removed  the  old 
fear  of  cceliotoniy ;  and  we  know  now  that  if  the  mother,  and  child 
are  in  a  hopeful  condition,  skill  and  care  will  usually  avail  to  save 
both.  There  need  be  no  fear  that  the  uterine  wound  will  not  readily 
heal,  for  it  has  been  found  well  closed,  in  a  case*  that  died  in  twenty- 
six  hours,  in  Philadelphia,  from  conditions  existing  prior  to  the  opera- 
tion. There  is  nothing  in  the  idea  that  the  process  of  involution  in 
the  uterus  is  antagonistic  to  that  of  union  by  the  first  intention. 
When  the  uterine  wound  was  not  closed,  or  when  it  was  sutured  with 
catgut,  gaping  often  took  place,  but  it  does  not  do  this  now,  where  the 
individual  tension  is  made  light  by  being  divided  among  many  sutures 
of  carbolized  silk.  It  is  not  required  to  use  fifty  stitches,  as  has  been 
done  in  a  few  instances,  but  a  dozen  each  of  deep  and  superficial  Avill 
make  a  good  average.  A  dozen  or  even  less  of  deep  stitches  alone 
have  answered  in  the  Cameron  cases ;  but  we  prefer  the  example  of 
Leipzig  and  Dresden,  where  the  maternal  loss  has  been  7^  per  cent. 
It  should  be  remembered  that  a  uterus  heals  the  most  readily  whose 
muscular  fibres  have  not  been  overtaxed  and  injured  by  long-con- 
tinued and  fruitless  action,  and  it  should  be  borne  in  mind  that  anaemia 
from  hemorrhage,  a  dead  foetus  in  utero,  and  the  exhaustion  of  long 
labor,  favor  the  production  of  sepsis,  septic  peritonitis,  and  fatal  shock. 
Where  the  uterus  contains  a  decomposing  foetus,  the  Porro  exsection 
should  be  performed  as  the  only  hope  of  avoiding  death  by  septic 
absorption ;  cures  have  been  secured  in  this  way  under  very  desperate 
conditions. — ED.] 


CCELIO-ELYTROTOMY.  553 


CHAPTER    VII. 

CCELIO-ELYTROTOMYF]  AND  SYMPHYSEOTOMY. 

BEARING  in  mind  the  great  mortality  attending  the  Csesarean  sec- 
tion, it  is  not  surprising  that  obstetricians  should  have  anxiously  con- 
sidered the  possibility  of  devising  substitutes  which  should  afford  the 
mother  a  better  chance  of  recovery.  Two  proposals  of  this  kind  have 
been  suggested,  and  from  both  great  results  were  anticipated. 

Coelio-elytrotomy. — One  of  these  is  the  operation  of  coelio-elytrotr- 
omy  as  perfected  by  Thomas,  of  New  York,  in  1870.  For  some 
years  subsequent  to  that  date  it  attracted  considerable  attention  and 
was  frequently  performed.  The  results  were  on  the  whole  promising : 
out  of  fourteen  cases,  seven  mothers  recovered  and  nine  children  were 
born  alive;  and  there  was  good  reason  to  expect  a  still  higher  success 
as  the  technique  of  the  operation  was  perfected  and  greater  experience 
was  acquired  in  its  performance.  The  improved  Csesarean  section  and 
Porro's  operation  have,  however,  of  late  years  shown  such  good  re- 
sults that  coelio-elytrotomy  has  fallen  into  disfavor.  It  does  not 
appear  to  have  been  performed  since  1887,  and  as  it  is  a  complex  and 
difficult  procedure  it  is  not  likely  again  to  be  adopted ;  nor,  with  the 
lessened  mortality  of  the  Csesarean  section,  is  there  any  reason  why  it 
should  be.  I,  however,  retain  the  account  of  it  as  a  matter  of  obstetric 
interest. 

History. — The  earliest  suggestion  of  a  procedure  of  this  character 
seems  to  have  been  made  by  Joerg  in  the  year  1806,  who  proposed  a 
modified  Csesarean  section  without  incision  of  the  uterus,  by  the  divi- 
sion of  the  linea  alba  and  of  the  upper  part  of  the  vagina,  the  foetus 
being  extracted  through  the  cervix.  This  suggestion  was  never  car- 
ried into  practice,  and  it  is  obvious  that  it  misses  the  one  chief  advan- 
tage of  coelio-elytrotomy,  the  leaving  of  the  peritoneum  intact.  In 
1820  Ritgen  proposed  and  actually  attempted  an  operation  much 
resembling  Thomas's,  in  which  section  of  the  peritoneum  was  avoided. 
He  failed,  however,  to  complete  it,  and  was  eventually  compelled  to 
deliver  his  patient  by  the  Csesarean  section.  In  1823,  Baudelocque 
the  younger,  independently  conceived  the  same  idea,  and  actually  car- 
ried it  into  practice,  although  without  success.  Lastly,  in  1837, 
Sir  Charles  Bell  suggested  a  similar  operation,  clearly  perceiving  its 
advantages.  Hence  it  appears  that  previous  to  Thomas's  recent  work 
in  the  matter,  the  operation  was  independently  invented  no  less  than 
three  times.  It  fell,  however,  entirely  into  oblivion,  and  was  only 
occasionally  mentioned  in  systematic  works  as  a  matter  of  curious 
obstetric  history,  no  one  apparently  appreciating  the  promising  char- 
acter of  the  procedure. 

£i  From  kottia,  the  abdomen ;  elytron,  the  vagina,  and  lomx,  to  cut. — ED.] 


654  OBSTETRIC  ^OPERATIONS. 

In  the  year  1870,  Dr.  T.  Gaillard  Thomas,  of  New  York,  read  a 
paper  before  the  Medical  Association  of  Yonkers,  entitled  "Gastro- 
elytrotomy,  a  Substitute  for  the  Csesarean.  Section/'  in  which  he  de- 
scribed the  operation  as  he  had  performed  it  three  times  on  the  dead 
subject,  and  once  on  a  married  woman  in  1870,  with  a  successful  issue 
as  regards  the  child.  It  seems  beyond  doubt  that  Thomas  invented 
the  operation  for  himself,  being  ignorant  of  Ritgen's  and  Baudelocque's 
previous  attempts,  and  it  is  certain,  to  quote  Garrigues,1  that  to  him 
"belongs  the  glory  of  having  been  the  first  who  performed  coelio- 
elytrotomy  so  as  to  extract  a  living  child  from  a  living  mother  in  his 
first  operation,  and  of  having  brought  both  mother  and  child  to  com- 
plete recovery  in  his  second  operation." 

Since  Thomas's  first  case,  the  operation  has  been  performed  several 
times  in  America,  and  has  found  its  way  across  the  Atlantic,  having 
been  twice  performed  in  England,  by  Himes  in  Sheffield,  by  Edis  in 
London ;  and  by  Poullet  in  Lyons,  France. 

Nature  of  the  Operation. — The  object  cf  ccelio-elytrotomy  is  to 
reach  the  cervix  by  incision  through  the  lower  part  of  the  abdominal 
wall  and  upper  part  of  the  vagina,  and  through  it  to  extract  the  foetus 
as  may  most  easily  be  done. 

Advantages  over  the  Caesarean.  Section. — The  advantages  it 
offers  over  the  Csesarean  section  are  that  in  dividing  the  abdomen  the 
abdominal  wall  only  is  incised,  and  the  peritoneum  is  left  intact.  The 
vagina  is  divided,  but  incision  of  the  uterine  parietes,  which  forma 
one  of  the  chief  risks  of  the  Ca?sarean  section,  is  entirely  avoided. 

Cases  Suitable  for  the  Operation. — It  may  be  broadly  stated  that 
coelio-elytrotomy  is  applicable  in  all  cases  calling  for  the  Caesarean  section 
when  the  mother  is  alive.  In  post-mortem  extractions  of  the  foetus, 
the  Caesarean  section,  being  the  most  rapid  procedure,  would  certainly 
be  preferable.  Exceptions  must  be  made  for  certain  cases  of  morbid 
conditions  of  the  soft  parts  which  render  delivery  per  vias  nalurales 
impossible,  and  in  which  ccelio-elytrotomy  could  not  be  performed,  as  in 
cases  of  tumor  obstructing  the  pelvic  cavity,  also  in  carcinoma  and  fibroid 
of  the  uterus.  When  the  head  is  firmly  impacted  in  the  pelvic  brim,  and 
cannot  be  dislodged,  the  operation  would  be  impossible,  as  the  vagina 
could  not  be  incised.  Unlike  the  Caesarean  section,  the  operation  can- 
not be  performed  twice  on  the  same  patient,  at  least  on  the  same  side, 
since  adhesions  left  by  the  former  incisions  would  prevent  the  separa- 
tion of  the  peritoneum  and  division  of  the  vagina.  It  remains  to  be 
seen  whether  in  certain  cases  of  extreme  deformity,  with  pendulous 
abdomen  and  distorted  thighs,  the  site  of  incision  might  not  be  so 
difficult  to  reach  as  to  render  the  necessary  manoeuvres  impossible. 

Anatomy  of  the  Parts  concerned  in  the  Operation. — It  will 
facilitate  the  proper  comprehension  of  the  operation,  and  render  an 
avoidance  of  its  possible  dangers  more  easy,  if  the  anatomical  relations 
of  the  parts  concerned  arebriefly  described. 

The  abdominal  incision  extends  from  a  point  an  inch  above  the 
anterior  superior  iliac  spine,  and  is  carried,  with  a  slight  downward 

1  New  York  Med.  Journ.,  1878,  vol.  xxviii.  pp.  337,  449. 


CCELIO-ELYTROTOMY.  555 

curve,  parallel  to  Poupart's  ligament  until  it  reaches  a  point  one  inch 
and  three-quarters  above,  and  to  the  outside  of,  the  spine  of  the  pubes. 
Beyond  the  latter  point  it  must  not  extend,  so  as  to  avoid  the  risk  of 
wounding  the  round  ligament  and  the  epigastric  artery.  In  this  incision 
the  skin,  the  aponeurosis  of  the  external  oblique,  and  the  fibres  of  the 
internal  oblique  and  transversalis  muscles  are  divided.  The  rectus  is 
not  implicated.  After  the  muscles  are  divided  the  transversalis  fascia 
is  reached.  It  is  fortunately  rather  dense  in  this  situation,  and  is 
separated  from  the  peritoneum  by  a  layer  of  connective  tissue  con- 
taining fat. 

The  superficial  epigastric  artery  is  necessarily  divided,  but  is  too 
small  to  give  any  trouble.  The  internal  epigastric  is  fortunately  not 
divided,  but  is  so  near  the  inner  end  of  the  incision  that  it  may  acci- 
dentally be  so.  In  one  of  Dr.  Skene's  operations  it  was  laid  bare. 
Starting  from  the  external  iliac,  about  a  quarter  of  an  inch  above 
Poupart's  ligament,  it  runs  downward,  forward,  and  inward  to  the 
ligament,  thence  it  turns  upward  and  inward,  in  front  of  the  round 
ligament  and  to  the  inner  side  of  the  internal  abdominal  ring,  behind 
the  posterior  layer  of  the  sheath  of  the  rectus  muscle,  which  it  finally 
enters.  The  circumflex  iliac  artery  also  rises  from  the  external  iliac  a 
little  below  the  epigastric.  It  runs  between  the  peritoneum  and  Pou- 
part's ligament  until  it  reaches  the  crest  of  the  ilium,  to  the  inner  side 
of  which  it  runs.  It  thus  lies  altogether  below  the  line  of  the  incision, 
and  is  not  likely  to  be  injured. 

After  the  transversalis  fascia  is  divided  the  peritoneum  is  reached, 
and  is  readily  lifted  up  intact,  so  as  to  expose  the  upper  part  of  the 
vagina,  through  which  the  foetus  is  extracted.  It  is  fortunate,  as  facili- 
tating this  manoeuvre,  that  the  peritoneum  is  much  more  lax  than  in 
the  non-pregnant  state,  and  it  has  been  found  very  easy  to  lift  it  out  of 
the  way  in  all  the  operations  hitherto  performed. 

The  division  of  the  vagina  is  the  part  of  the  operation  likely  to  give 
rise  to  most  trouble  and  risk.  It  is  to  be  noted  that,  in  cases  of  pelvic 
contraction  calling  for  this  operation,  the  uterus,  with  its  contents,  will 
be  abnormally  high  and  altogether  above  the  pelvic  brim  ;  the  vagina 
is,  therefore,  necessarily  elongated  and  brought  more  readily  within 
reach.  It  is  enlarged  in  its  upper  part  during  pregnancy,  and  thrown 
into  folds  ready  for  dilatation  during  the  passage  of  the  child.  It  is 
loosely  surrounded  by  the  other  tissues,  and  is  composed  of  muscular 
fibres,  easily  separable,  and  an  internal  mucous  layer.  Its  vascular 
arrangements  are  very  complex,  and  the  risk  of  hemorrhage  is  one  of 
the  prominent  difficulties  of  the  operation. 

In  Baudelocque's  attempt,  in  which  the  vagina  was  cut  instead  of 
torn,  the  loss  of  blood  was  so  great  as  to  lead  to  a  discontinuance  of  the 
operation.  The  arteries  are  numerous,  consisting  of  branches  from  the 
hypogastric,  inferior  vesical,  internal  pudic,  and  hemorrhoidal.  The 
veins  form  a  network  surrounding  the  whole  canal,  but  are  largest  at  its 
extremities,  so  that  it  is  desirable  to  open  the  vagina  as  low  down  as 
possible. 

Behind  the  vagina  lies  the  pouch  of  peritoneum  known  as  Douglas's 
space,  and  below  that  the  rectum.  In  front  of  it  lies  the  bladder,  and 


556  OBSTETRIC    OPERATION'S. 

the  risk  of  injuring  that  viscus  or  the  ureter  entering  it  constitutes 
another  of  the  dangers  of  the  operation.  The  relations  of  these  parts 
have  been  specially  studied  by  Garrigues,1  with  the  view  of  facili- 
tating the  safe  performance  of  the  operation,  and  I  quote  his  descrip- 
tion : 

"The  anterior  superior  surface  of  the  vagina  is,  in  its  upper  part, 
bound  by  loose  connective  tissue  to  the  bladder  on  a  surface  that  has 
the  shape  of  a  heart.  In  the  lower  or  anterior  part,  the  boundary  line 
of  this  surface  runs  parallel  to,  and  a  little  outside  of,  the  triyonum 
vesicale.  In  the  upper  part  it  follows  the  outline  of  the  vagina,  from 
which  it  passes  over  to  the  cervix.  The  distance  from  the  internal 
opening  of  the  urethra  to  the  neck  of  the  womb  is  one  inch  and  a 
quarter  (3.2  centimetres).  The  bladder  extends  five-eighths  of  an  inch 
(1.5  centimetres)  upon  the  cervix.  It  is  very  liable  to  be  reached  by 
the  vaginal  rent,  if  the  latter  is  made  too  high  up  or  too  horizontal. 
The  lower  part  of  the  antero-superior  wall  carries  in  the  middle  line 
the  urethra.  In  the  uppermost  part,  a  little  outside  of  and  behind  the 
bladder,  lies  the  ureter.  In  order  to  avoid  the  ureter  and  the  bladder, 
the  incision  of  the  vagina  should  be  made  nearly  an  inch  and  a  half 
(3.8  centimetres)  below  the  uterus,  and  in  a  direction  parallel  to  the 
ureter  and  the  boundary  line  between  the  bladder  and  the  vagina." 

The  Operation. — The  operation  has  hitherto  been  performed  chiefly 
on  the  right  side.  In  consequence  of  the  position  of  the  rectum  on  the 
left,  it  seemed  doubtful  if  the  difficulties  of  performing  it  on  that  side 
would  not  render  the  operation"  impossible.  It  has,  however,  been 
performed  three  times  on  the  left  side,  and  apparently  as  easily  as  on 
the  right.  For  the  proper  performance  of  the  operation  four  assistants 
are  necessary,  besides  one  who  administers  the  anaesthetic.  The  patient 
is  placed  on  her  back  on  the  operating-table,  with  the  pelvis  raised 
and  in  the  same  position  as  for  ovariotomy.  In  consequence  of  access 
of  air  per  vaginam  strict  antiseptic  precautions  cannot  be  adopted. 
Before  commencing  the  operation  the  cervix  is  dilated  as  much  as 
possible  by  Barnes's  bags,  assisted,  if  necessary,  by  digital  dilatation. 

The  operator  stands  on  the  right  side  of  the  patient,  while  an 
assistant,  standing  on  her  left,  lays  his  hand  on  the  uterus  and  draws 
it  upward  and  to  the  left,  so  as  to  put  the  skin  on  the  stretch.  The 
incision  is  commenced  at  a  point  one  inch  above  the  anterior  superior 
spine  of  the  ilium,  and  is  carried  inward  in  a  slightly  curved  direction 
until  it  reaches  a  point  one  and  three-quarters  inches  above  and  outside 
the  spine  of  the  pubes.  The  skin,  muscular  and  aponeurotic  tissues 
are  carefully  divided,  layer  by  layer,  any  arterial  branches  being 
secured  as  they  are  severed,  until  the  transversal  is  fascia  is  reached. 
This  is  raised  by  a  fine  tenaculum.  and  an  aperture  is  made  in  it 
through  which  a  director  is  introduced,  and  on  this  the  fascia  is  divided 
in  the  whole  length  of  the  superficial  incision.  The  operator  now  sepa- 
rates the  peritoneum  from  the  transversalis  and  iliac  fascia  witli  his 
fingers,  and  an  assistant,  placed  on  his  left,  elevates  it,  as  well  as  the 
contained  intestines,  by  means  of  a  fine  warmed  napkin,  and  keeps  it 

1  Loc.  cit.,  p.  479. 


SYMPHYSEOTOMY.  557 

well  out  of  the  way  during  the  rest  of  the  operation.  A  third  assistant 
now  introduces  a  silver  catheter  into  the  bladder,  and  holds  it  in  the 
position  of  the  boundary  line  between  it  and  the  vagina,  and  below  the 
uterus. 

A  blunt  wooden  instrument  like  the  obturator  of  a  speculum  is 
introduced  into  the  vagina,  which  is  pushed  up  by  it  above  the  ilio- 
pectineal  line.  On  this  an  incision  is  made  by  Paquelin's  thermo- 
cautery  heated  to  a  red  heat  only,  as  far  below  the  uterus  as  possible, 
and  parallel  to  the  ilio-pectineal  line  and  the  catheter  felt  in  the 
bladder.  When  the  vagina  has  been  burnt  through,  the  index  fingers 
of  both  hands  are  pushed  through  the  incision,  and  the  vagina  torn 
through  as  far  forward  as  is  deemed  safe  by  the  guide  of  the  catheter 
in  the  bladder,  and  as  far  backward  as  possible.  When  this  has 
been  done  the  uterus  is  depressed  to  the  left,  and  the  cervix  lifted 
into  the  incision  by  the  fingers,  and  the  membranes  are  ruptured. 
Through  the  cervix  thus  elevated  the  child  is  extracted,  according  to 
the  presentation,  either  by  simple  traction,  by  the  forceps,  or  by  turn- 
ing. Before  concluding  the  operation  the  bladder  should  be  injected 
with  milk  to  make  sure  that  it  has  not  been  wounded.  Should  it  be 
so,  the  laceration  may  be  at  once  united  by  carbolized  gut.  The  prin- 
cipal risk  at  this  stage  is  hemorrhage  from  the  vaginal  vessels,  which, 
however,  fortunately  did  not  give  rise  to  much  trouble  in  any  of  the 
recent  operations.  If  it  occurs  it  must  be  dealt  with  as  best  we  can, 
either  by  ligature,  by  the  actual  cautery,  or  by  thoroughly  plugging 
the  vaginal  wound  with  cotton  both  through  the  incision  and  per 
vaginam.  If  the  latter  be  not  necessary,  the  wound  should  be  cleaned 
by  injecting  a  warm  solution  of  weak  carbolized  water  (2  per  cent.), 
its  edges  united  by  interrupted  sutures,  and  dressed  as  is  deemed  best. 
The  subsequent  treatment  must  be  conducted  on  general  surgical 
principles,  and  will  much  resemble  that  necessary  after  other  severe 
abdominal  operations,  such  as  ovariotomy.  The  vagina  should  be 
gently  syringed  two  or  three  times  daily  with  a  weak  antiseptic  lotion. 
The  diet  should  be  light  and  nutritious,  chiefly  consisting  of  milk,  beef- 
tea,  and  the  like.  Pain,  pyrexia,  etc.,  must  be  treated  as  they  arise. 

Symphyseotomy. — The  second  operation  requires  a  more  extended 
notice  than  in  former  editions  of  this  work,  since  it  has  been  revived 
within  the  last  few  years,  chiefly  under  the  auspices  of  Professor  Mori- 
sani,  of  Naples,  and  has  now  been  performed  in  a  large  number  of 
cases,  as  an  alternative  to  craniotomy,  and  with  very  considerable 
success. 

Its  History. — In  1768  Sigault,  then  a  medical  student  in  Paris, 
suggested  symphyseotomy,  which  consists  in  a  division  of  the  symphysis 
pubis,  with  a  view  of  allowing  the  pubic  bones  to  separate  sufficiently 
to  admit  of  the  passage  of  the  child.  [x]  Although  at  first  strongly 
opposed,  it  was  subsequently  ardently  advocated  by  many  obstetricians, 
and  frequently  resorted  to  on  the  Continent.  In  1778  the  operation 
was  performed  thirteen  times  in  Germany,  France,  and  Belgium;  once 
only  in  England,  in  1782.  Since  that  time  it  gradually  fell  into  dis- 

[l  The  proposition  was  made  originally  in  the  work  of  Severin  Pineau,  which  he  is  known  to 
have  had.— ED.] 


558  OBSTETRIC    OPERATIONS. 

favor,  and  may  be  said  to  have  become  practically  obsolete,  a  few  cases 
only  having  occasionally  been  operated  on  in  Italy,  where  suitable 
cases  of  pelvic  deformity  appear  to  be  very  common.  In  1863  Prof. 
Morisani,  of  Naples,  undertook  a  study  of  the  operation  on  the  dead 
subject,  and  came  to  the  conclusion  that  it  had  'a  sound  basis,  and 
in  1866  he  operated  on  a  living  woman,  saving  both  the  mother  and 
child.  Since  January  1,  1886,  it  had  been  performed,  up  to  the  end 
of  1892,  in  115  cases  in  Europe  and  America,  with  9  maternal  deaths 
and  24  children  lost.  Up  to  this  time  it  has  been  attempted  but  once 
each  in  Ireland  and  England. 

These  figures  are  certainly  very  striking,  and  the  remarkably  dimin- 
ished mortality  is  beyond  doubt  due  to  the  application  of  careful  anti- 
sepsis and  improved  technique.  The  maternal  mortality  will  certainly 
contrast  favorably  with  that  attending  an  equal  number  of  severe 
crauiotomies,  in  all  of  which  the  children  would  have  been  sacrificed. 
It  is  to  be  noted,  however,  that  this  operation  can  never  take  the  place 
of  the  Csesarean  section  in  extreme  cases  of  pelvic  deformity,  but  is 
rather  a  substitute  for  craniotomy  in  slighter  cases,  chiefly  in  flattened 
pelves,  which  are  just  too  small  to  admit  of  the  passage  of  a  living 
child.  It  is  not  applicable  in  cases  of  obliquely  contracted  pelvis,  or 
in  cases  in  which  delivery  is  obstructed  by  tumors  of  any  kind,  bony 
growths,  or  carcinoma.  It  has  also  been  suggested  in  certain  cases  in 
Avhich  the  head  is  impacted  in  consequence  of  malpresentation,  such  as 
mento-posterior  positions  of  the  face,  or  in  brow  presentations,  in  which 
craniotomy  would  otherwise  be  necessary.1  Any  alternative  that  will 
avoid  the  destruction  of  a  living  foetus  is  surely  well  worthy  of  con- 
sideration, and  there  can  be  little  doubt  that  the  recent  happy  results 
following  the  revival  of  symphyseotomy  will  lead  to  its  adoption  in 
suitable  cases.  The  operation  itself  is  by  no  means  difficult,  and  it 
requires  less  surgical  skill  than  the  Csesareau  section,  or  Porro's  opera- 
tion, or  a  difficult  crauiotomy. 

Limits  of  the  Operation. — Professor  Morisani  lays  down  two  and 
five-eighths  inches  as  the  limits  below  which  symphyseotomy  is  im- 
practicable. It  would,  of  course,  be  a  matter  of  great  moment  to 
ascertain  the  exact  dimensions  of  the  sacro-pubic  diameter  accurately, 
whenever  the  operation  is  contemplated,  but  as  the  necessity  for  this 
may  not  arise  until  the  patient  is  actually  in  labor,  this  may  not  always 
be  practicable.  It  is,  however,  in  cases  with  a  conjugate  larger  than 
this,  in  Avhich  we  would  otherwise  be  obliged  to  resort  to  perforation, 
that  this  alternative  will  most  frequently  present  itself  in  the  hope  of 
saving  the  life  of  the  child.  It  is  in  such  cases  as  the  following, 
quoted  by  Harris,  in  which  the  contraction  is  not  excessive,  that  sym- 
physeotomy will  probably  find  its  best  application  :  "The  patient  was 
in  labor  for  the  third  time.  Her  first  child  having  been  a  large  one, 
perished ;  the  second  being  much  smaller,  lived ;  and  the  third  was 
again  too  large  to  pass.  She  had  a  diagonal  conjugate  of  100  milli- 
metres (four  inches),  and  probably  three  and  three-quarters  inches  in 
the  true  conjugate.  The  foetus,  which  was  arrested  at  the  superior 

1  "  Symphyseotomy— a  Successful  Case,"  by  J.  Ed  win  Michael,  M.A.,  M.D.     Amer.  Journ.  of 
Obstet.,  February,  1893,  p.  183. 


SYMPHYSEOTOMY. 


559 


strait,  was  delivered  in  fifteen  minutes,  by  the  vertex  under  manual 
assistance,  after  her  pubes  had  been  opened  by  the  knife.     The  child 


FIG.  200. 


MAT  SIZE 

Sections  of  pelvic  brim  to  illustrate  symphyseotpmy.    (After  PINARD.) 

was  saved  instead  of  perishing  under  the  perforator;  the  mother  made 
a  good  recovery,  and  was  well  in  thirty  days." 

Having  no  personal  experience  of  this  operation,  I  can  give  no 
opinion  on  its  merits,  beyond  the  obvious  remark  that  anything  that 


560  OBSTETRIC    OPERATIONS. 

tends  to  minimize  the  resort  to  the  horrible  operation  of  craniotomy, 
without  materially  increasing  the  risk  to  the  mother,  which  the  figures 
so  far  show  that  this  operation  promises  to  do,  is  well  worthy  of  the 
most  serious  study  and  consideration. 

The  accompanying  diagrams  (Figs.  200,  201)  will  give  an  idea  of 
the  increased  pelvic  dimensions  obtained  by  symphyseotomy.  It  rep- 
resents sections  at  the  pelvic  brim  made  on  a  subject  who  had  died 
nine  days  after  delivery  at  term.  After  division  of  the  symphysis  a 
separation  of  three  inches  took  place,  which  is  the  average  amount  to 
be  expected,  and  this  gives  about  an  inch  gain  on  all  the  pelvic  diam- 
eters. This  increase  is  well  illustrated  by  the  second  figure,  which 
shows  the  same  section  with  the  pubic  bones  placed  in  contact. 

Description  of  the  Operation. — The  operation  itself  is  very  simple. 
I  cannot  describe  it  better  than  in  the  words  of  Dr.  Harris : 

"  The  armamentarium  required  is  very  simple,  viz. :  a  scalpel ; 
Galbiati's  probe-pointed  sickle-shaped  bistoury1  (Fig.  202) ;  some 
haemostatic  forceps ;  a  needle-holder  and  needles ;  a  metallic  catheter ; 
ligature  silk ;  gauze  and  cotton.  After  sterilizing  these,  place  the 
parturient  woman  on  her  back,  on  an  operating-table,  with  her  knees 

FIG.  202. 


Galbiati's  sickle-shaped  bistoury. 

drawn  up  and  separated,  shave  the  mons  Veneris  and  labia  majora, 
and  disinfect  the  supra-pubic  region,  the  vulva,  the  perineum,  and 
vulvo-vaginal  canal.  Examine  the  depth,  thickness,  and  direction  of 
the  symphysis,  and  search  out  the  fossa  in  its  superior  edge  which 
marks  the  point  of  union  of  the  two  pubic  bones ;  then  examine  the 
inferior  margin  and  the  anterior  and  posterior  faces  of  the  pubes. 

"  Introduce  the  female  catheter  and  give  it  into  the  hand  of  an 
assistant,  that  he  may  depress  the  urethra  from  the  pubic  arch,  and  at 
the  same  time  carry  it  to  the  right  side,  to  save  it  from  injury.  Make 
a  vertical  incision  through  the  skin  and  fat  above  the  pubes,  about 
two  to  two  and  one-hall  inches  in  length,  ending  about  three-fourths 
of  an  inch  above  the  symphysis,  cutting  the  tissues  gently  and  passing 
in  a  line  down  to  the  insertion  of  the  recti  muscles.  Detach  for  a 
short  space  the  recti  muscles  from  their  attachment  to  the  two  ossa 
pubes ;  introduce  the  left  index  finger  into  the  opening,  and  separate 
the  retro-pubic  tissue.  Then  apply  the  palmar  face  of  the  finger  directly 
against  the  posterior  face  of  the  symphysis,  hooking  with  it  the  in- 
ferior margin  of  the  articulation,  while  the  assistant  attends  to  the 
catheter  as  stated.  The  operator  then  introduces  the  Galbiati  bistoury 
and  hooks  it  around  the  articulation,  cutting  the  interosseous  ligaments 

»  An  ordinary  probe-pointed  curved  bistoury  may  be  used  instead  of  this  special  knife. 


SYMPHYSEOTOMY.  561 

and  cartilage  from  within  outward  and  below  upward.  When  the 
section  has  been  completed  it  will  be  known  by  a  creaking  sensation 
and  a  separation  of  the  bones  from  one  and  one-quarter  to  one  and 
one-half  inches. 

"After  this  step,  cover  the  wound  with  the  gauze,  dipped  in  a 
bichloride  solution  of  1  :  4000,  and  attend  to  the  delivery  of  the  foetus, 
having  at  the  same  time  the  separation  of  the  innominate,  antagonized 
by  pressure  Avith  the  hands  of  assistants.  During  the  passage  of  the 
head  ascertain  the  amount  of  pubic  separation  ;  spray  the  vagina ;  and 
when  the  placenta  is  delivered,  introduce  six  or  eight  interrupted  silk 
sutures  into  the  edges  of  the  wound ;  dress  it  with  sublimated  cotton, 
1  :  2000,  and  bandage  the  pelvis  and  lower  extremities." 

Pinard1  prefers  to  divide  the  pubes  from  without  inward  with  a 
straight  bistoury,  protecting  the  subjacent  structures  with  the  index 
finger  of  the  left  hand  previously  passed  behind  it. 

One  would  naturally  fear  that  after  the  section  of  the  symphysis, 
and  the  strain  put  on  the  sacro-iiiac  joints  by  the  separation  of  the  in- 
nominate bones,  subsequent  difficulties  in  locomotion  would  arise.  No 
mention  is  made  of  this  in  the  cases  hitherto  published,  but  the  point 
appears  to  require  further  investigation.^] 

[FIG.  203. 


Harris's  symphyseotomy  bistoury.    This  is  modelled  to  conform  with  the  posterior  curve  of  the 
symphysis  from  above  downward. — ED.] 

After  the  incision  is  made  and  the  symphysis  separated,  it  may,  of 
course,  be  necessary  to  complete  delivery  either  by  the  high  forceps 
operation  or  by  version. 

[Progress  and  Results  of  Symphyseotomy. — Until  February  4, 
1892,  this  operation  was  for  many  years  confined  to  Italy,  and  for 
twenty -seven  years  almost  entirely  to  Naples,  in  which  city  there  were 
twelve  women  delivered  under  it  in  1891.  On  the  date  mentioned  it 
reappeared  in  Paris,  and  soon  commenced  to  be  performed  in  other 
countries ;  but  not  with  the  success  that  had  attended  it  in  Italy 
during  1886-91.  Although  originally  a  French  operation,  it  had 
fallen  into  very  bad  repute,  and  had  for  many  years  been  considered 
as  beyond  the  pale  of  obstetric  surgery.  In  its  restoration  to  favor  it 
again  became  the  operation  of  Sigault,  and  was  performed  by  direct 
incision,  and  not  by  the  sub-osseous  method,  which  under  Morisani 
and  Novi,  of  Naples,  in  an  experience  of  twenty-six  years  (1866-91), 
had  procured  it  a  reputation  of  success  and  safety.  The  successes  of 
Pinard,  of  Paris,  gave  the  method  a  new  impetus,  and  it  has  rapidly 
spread  into  other  countries,  where  it  has  been  performed  with  varying 
success ;  but  in  no  locality  with  the  low  death-rate  of  Italy,  where  46 

i  Symphyseotomy  at  the  Clinique  Baudelocque,  Lancet,  February  18,  1 893. 
[2  Difficulty  in  locomotion  has  very  rarely  followed  the  operations  under  antisepsis  and  pelvic 
fixation,  and  the  disability  has  been  temporary.— ED.] 

36 


562  OBSTETRIC    OPERATIONS. 

deliveries  cost  the  lives  of  only  2  women  and  5  children,  dating  from 
1886. 

Although  Prof.  Pinard  did  not  lose  a  case  until  his  twentieth  died 
of  direct  sepsis,  no  other  operator  or  country  out  of  Naples  had  this 
measure  of  success.'  France  lost  5  out  of  her  first  35,  including  8 
successes  of  Pinard ;  and  the  United  States  lost  4  out  of  her  first  25. 
In  sixteen  months  (February  1,  1892,  to  June  1,  1893)  the  operatiou 
was  tested  in  eleven  countries  and  upon  more  than  150  women. 

If  we  include  the  Italian  operations  of  1886-91,  we  find  that,  up  to 
June  of  this  present  year,  there  were  25  women  and  37  children  lost 
under  205  symphyseotomic  deliveries,  according  to  the  record  made 
by  Neugebauer,  of  Warsaw,  with  my  assistance.  This  would  leave, 
without  the  46  of  Italy,  23  deaths  in  159  women,  and  32  children 
lost.  Not  a  very  encouraging  record  when  compared  with  the  Caesarean 
results  of  Leipzig  and  Dresden,  a  mortality  of  7  per  cent. 

Symphyseotomy,  although  an  old  operation,  is  still  in  the  experi- 
mental period  of  its  existence  in  all  localities  outside  of  Naples,  and 
we  should,  in  our  country  at  least,  be  content  to  follow  the  directions 
given  by  Morisani,  as  already  stated.  Several  prominent  operators 
have  been  very  much  disappointed  with  the  results  attained  in  their 
hands,  while  others,  more  successful,  are  disposed  to  commend  the 
method.  In  our  own  country  it  is  believed  to  have  a  promising  future ; 
to  secure  which  the  operation  by  direct  incision  is  to  be  avoided,  as  the 
results  in  France  and  Vienna  do  not  commend  it. 

Having  for  t\velve  years  studied  this  operation  by  correspondence, 
I  am  inclined  to  regard  it  in  the  light  of  its  measure  of  possibility,  as 
shown  by  the  work  of  the  last  six  and  one-half  years  in  Naples,  rather 
than  by  the  actual  average  of  success  elsewhere  in  the  past  eighteen 
months.  There  does  not  now  appear  to  be  any  element  of  danger 
arising  from  injury  done  to  the  sacro-iliac  synchondroses.  "What  they 
have  most  to  fear  in  Continental  maternities  is  septic  poisoning  from 
the  wound  in  the  symphysis,  or  from  lacerations  of  the  cervix,  vagina, 
vulva,  and  perineum,  all  of  which  sometimes  occur  in  the  same  sub- 
ject, and  particularly  in  rhachitic  primiparae.  It  should  be  borne  in 
mind  that  in  cases  where  the  pelvis  is  much  contracted,  the  vagina  and 
vulva  will  usually  be  found  to  be  of  the  same  character,  and  an  oper- 
ator cannot  be  too  cautious  in  making  slow  and  interrupted  traction 
with  his  forceps, 

The  minimum  conjugate  diameter  of  Morisani  of  two  and  five- 
eighths  inches  is  too  small  for  this  country,  where  the  foetus  is  on  the 
average  of  larger  size,  and  should  be  fixed  at  two  and  three-quarters 
inches ;  and  even  this  will  be  found  a  dangerous  measure  where  the 
foetus  is  a  male  and  above  the  average  weight.  If  a  woman  is  oper- 
ated upon  in  good  season,  and  by  the  sub-osseous  section,  she  should 
run  but  a  moderate  risk  for  her  life,  and  her  child  likewise ;  although 
the  latter  has  a  less  degree  of  safety.  According  to  Dr.  Franz  Neuge- 
bauer,  the  general  average  of  death  for  the  women  is  now  12  per  cent., 
and  for  the  children,  18.  In  the  United  States  the  average  has  been, 
respectively,  16  per  cent,  and  24  per  cent.  This  statement  has  dis- 
appointed many  of  our  accoucheurs ;  but  if  they  will  examine  into  the 


SYMPHYSEOTOMY.  563 

causes  of  death  in  the  four  women,  they  will  find  encouragement  rather 
than  the  reverse.  Like  the  Csesarean  section,  much  will  depend  upon 
the  length  of  labor  and  the  condition  of  the  patient  when  operated  on 
for  securing  a  successful  issue.  Symphyseotomy  ought  to  be  less 
dangerous  than  the  Csesarcan  section  has  been  in  our  country ;  and 
nothing  short  of  this  should  satisfy  those  who  propose  to  substitute  it 
for  craniotomic  infanticide.  It  is  a  less  formidable  operation,  and 
women  make  less  objection  to  it  than  they  do  to  the  abdominal  delivery. 
It  requires  less  skill  in  its  execution,  and  is  not  so  shocking  in  its 
effects  upon  the  nerves  of  the  accoucheur ;  but  take  the  whole  delivery 
in  many  cases,  and  it  will  be  found  that  no  little  skill  is  required  to 
secure  a  favorable  result. 

Operation  after  Induced  Labor. — Where  the  true  conjugate  is 
below  the  minimum  measure,  the  disproportion  between  it  and  the 
size  of  the  foetal  head  may  be  overcome  by  bringing  on  labor  at  the 
end  of  the  eighth  mouth  or  a  little  later.  Children  thus  delivered 
require  extra  care  in  raising,  and  in  the  class  to  which  they  belong  are 
very  often  lost  at  an  early  period.  In  exceptional  instances  they  have 
done  remarkably  well ;  but  it  is  a  question  to  be  considered,  whether 
it  would  not  be  better  in  the  average  of  cases  to  deliver  by  the  Csesarean 
section  at  full  term. 

Unilateral  Ischio-pubiotomy. — Following  a  suggestion  of  Fara- 
beuf,  Prof.  Pinard  operated  upon  a  V-para  of  thirty-two  at  the  Clin- 
ique  Baudelocque  on  November  9, 1892,  so  as  to  deliver  a  living  male 
fetus,  weighing  nearly  nine  pounds,  through  an  oblique  Naegele  pelvis. 
He  cut  down  upon  the  ischio-pubic  ramus  of  the  ankylosed  side,  and 
divided  it  with  a  chain-saw ;  and  repeated  a  section  of  the  horizontal 
ramus  of  the  corresponding  os  pubis  at  a  distance  of  5  cm.  from  the 
symphysis.  This  enabled  him  to  open  out  the  front  of  the  pelvis  by 
the  separation  of  the  free  synchondrosis  of  the  opposite  side  under  the 
traction  of  Tarnier's  forceps ;  and  a  separation  of  the  os  pubis  to  the 
extent  of  4  cm.  gave  room  for  the  passage  of  the  foetus.  The  wound 
healed  by  the  first  intention  in  eight  days ;  the  woman  sat  up  in  thirty- 
two  days,  and  walked  about  without  inconvenience  in  two  months,  the 
child  then  weighing  eleven  pounds.1  This,  in  principle,  was  a  repeti- 
tion of  the  bi-pubiotomy  of  Galbiati,  of  Naples,  performed  upon  both 
sides  on  March  30,  1832,  with  a  fatal  result;  the  dwarf  of  three  and 
one-half  feet,  having  a  one-inch  conjugate,  dying  in  four  days.  The 
operation  of  Farabeuf  had  the  advantages  of  antisepsis,  and  of  a 
slight  disproportion  of  size  between  the  pelvic  canal  and  foetal  head. 
—ED.] 

»  Annales  de  Gynficol.  et  d'Obstet..  Fev.,  1893.  pp.  139-152. 


564:  OBSTETRIC    OPERATIONS. 


CHAPTER    VIII. 

THE   TRANSFUSION   OF   BLOOD. 

The  Transfusion  of  Blood  in  desperate  and  apparently  hopeless 
cases  of  hemorrhage  offers  a  possible  means  of  rescuing  the  patient 
which  merits  careful  consideration.  It  has  again  and  again  attracted 
the  attention  of  the  profession,  but  has  never  become  popularized  in 
obstetric  practice.  The  reason  of  this  is  not  so  much  the  inherent 
defects  of  the  operation  iiself — for  quite  a  sufficient  number -of  success- 
ful cases  are  recorded  to  make  it  certain  that  it  is  occasionally  a  most 
valuable  remedy — but  the  fact  that  the  operation  lias  been  considered 
a  delicate  and  difficult  one,  and  that  it  has  been  deemed  necessary  to 
employ  a  complicated  and  expensive  apparatus,  which  is  never  at  hand 
when  a  sudden  emergency  arises.  Whatever  may  be  the  difference  of 
opinion  about  the  value  of  transfusion,  I  think  it  must  be  admitted 
that  it  is  of  the  utmost  consequence  to  simplify  the  process  in  every 
possible  way ;  and  it  is  above  all  things  necessary  to  show  that  the 
•steps  of  the  operation  are  such  as  can  be  readily  performed  by  any 
ordinarily  qualified  practitioner,  and  that  the  apparatus  is  so  simple 
and  portable  as  to  make  it  easy  for  any  obstetrician  to  have  it  at  hand. 
There  are  comparatively  few  who  would  consider  it  worth  while  to 
carry  about  with  them,  in  ordinary  every -day  work,  cumbrous  and 
expensive  instruments  which  may  never  be  required  in  a  life-long 
practice ;  and  hence  it  is  not  unlikely  that,  in  many  cases  in  which 
transfusion  might  have  proved  useful,  the  opportunity  of  using  it  has 
been  allowed  to  slip.  Of  late  years  the  operation  has  attracted  much 
attention,  the  method  of  performing  it  has  been  greatly  simplified, 
and  I  think  it  will  be  easy  to  prove  that  all  the"  essential  apparatus 
may  be  purchased  for  a  few  shillings,  and  in  so  portable  a  form  as  to 
take  up  little  or  no  room ;  .so  that  it  may  be  always  carried  in  the 
obstetric  bag  ready  for  any  possible  emergency. 

History  of  the  Operation. — The  history  of  the  operation  "is  of  con- 
siderable interest.  In  Villari's  Life  of  Savonarola,  it  is  said  to  have 
been  employed  in  the  case  of  Pope  Innocent  VIII.,  in  the-  year  1492, 
but  I  am  not  aware  on  what  authority  the  statement  is  made.  The 
first  serious  proposals  for  its  performance  do  not  seem  to  have  been 
made  until  the  latter  half  of  the  seventeenth  century.  It  was  first 
actually  performed  in  France  by  Denis,  of  Montpellier,  although 
Lower,  of  Oxford,  had  previously  made  experiments  on  animals  which 
satisfied  him  that  it  might  be  undertaken  with  success.  In  November, 
1667,  some  months  after  Denis's  case,  he  made  a  public  experiment  at 
Arundel  House,  in  which  twelve  ounces  of  sheep's  blood  were  injected 
into  the  veins  of  a  healthy  man,  who  is  stated  to  have  been  very  well 


THE    TRANSFUSION    OF    BLOOD.  565 

after  the  operation,  which  must,  therefore,  have  proved  successful. 
These  nearly  simultaneous  cases  gave  rise  to  a  controversy  as  to  priority 
of  invention,  which  was  long  carried  on  with  much  bitterness. 

The  idea  of  resorting  to  transfusion  after  severe  hemorrhage  does 
not  seem  to  have  been  then  entertained.  It  was  recommended  as  a 
means  of  treatment  in  various  diseased  states,  or  with  the  extravagant 
hope  of  imparting  new  life  and  vigor  to  the  old  and  decrepit.  The 
blood  of  the  lower  animals  only  was  used  ;  and,  under  these  circum- 
stances, it  is  not  surprising  that  the  operation,  although  practised  on 
several  occasions,  was  never  established  as  it  might  have  been  had  its 
indications  been  better  understood. 

From  that  time  it  fell  almost  entirely  into  oblivion,  although  experi- 
ment: and  suggestions  as  to  its  applicability  were  occasionally  made, 
especially  by  Dr.  Harwood,  Professor  of  Anatomy  at  Cambridge,  who 
published  a  thesis  on  the  subject  in  the  year  1785.  He,  however, 
never  carried  his  suggestions  into  practice,  and,  like  his  predecessors, 
only  proposed  to  employ  blood  taken  from  the  lower  animals.  In  the 
year  1824  Dr.  Blundell  published  his  well-known  work  entitled 
Jlesearches,  Physiological  and  Pathological,  which  detailed  a  large 
number  of  experiments ;  and  to  that  distinguished  physician  belongs 
the  undoubted  merit  of  having  brought  the  subject  prominently  before 
the  profession,  and  of  pointing  out  the  cases  in  which  the  operation 
might  be  performed  with  hopes  of  success.  Since  the  publication  of 
this  work,  transfusion  has  been  regarded  as  a  legitimate  operation 
under  special  circumstances;  but,  although  it  has  frequently  been  per- 
formed with  success,  and  in  spite  of  many  interesting  monographs  on 
the  subject,  it  has  never  become  so  established  as  a  general  resource 
in  suitable  cases  as  its  advantages  would  seem  to  warrant.  Within 
the  last  few  years  more  attention  has  been  paid  to  the  subject,  and  the 
writings  of  Panum,  Martin,  and  De  Belina  on  the  Continent,  and  of 
Higginson,  McDonnell,  Hicks,  Aveling,  and  Schafer  in  Great  Britain, 
amongst  others,  have  thrown  much  light  on  many  points  connected 
with  the  operation. 

Nature  and  Object  of  the  Operation. — Transfusion  is  practically 
only  employed  in  cases  of  profuse  hemorrhage  connected  with  labor, 
although  it  has  boon  suggested  as  possibly  of  value  in  certain  other 
puerperal  conditions,  such  as  eclampsia  or  puerperal  fever.  Theo- 
retically it  may  be  expected  to  be  useful  in  such  diseases ;  but,  inas- 
much as  little  or  nothing  is  known  of  its  practical  effects  in  these 
diseased  states,  it  is  only  possible  here  to  discuss  its  use  in  cases  of 
excessive  hemorrhage.  Its  action  is  probably  twofold :  first,  the 
actual  restitution  of  blood  which  has  been  lost;  second,  the  supply  of 
a  sufficient  quantity  of  blood  to  stimulate  the  heart  to  contraction,  and 
thus  to  enable  the  circulation  to  be  carried  on  until  fresh  blood  is 
formed.  The  influence  of  transfusion  as  a  means  of  restoring  lost 
Mood  must  be  trivial,  since  the  quantity  required  to  produce  an  effect 
is  generally  very  small  indeed,  and  never  sufficient  to  counterbalance 
that  which  has  been  lost.  Its  stimulant  action  is  no  doubt  of  far  more 
importance ;  and  if  the  operation  be  performed  before  the  vital  energies 
are  entirely  exhausted,  the  effect  is  often  most  marked. 


566  OBSTETRIC    OPERATIONS. 

Use  of  Blood  taken  from  the  Lower  Animals. — In  the  earliest 
operations  the  blood  used  was  always  that  of  the  lower  animals,  gener- 
ally of  the  sheep.  It  has  been  thought  by  Brown-Sequard  and  others 
that  the  blood  of  some  of  the  lower  animals,  especially  of  those  in  which 
the  corpuscles  are  of  smaller  size  than  in  man,  as  of  the  sheep,  might 
be  used  with  safety,  provided  it  is  not  too  rich  in  carbonic  acid  and 
too  poor  in  oxygen,  and  injected  in  small  quantity  only.  Landois,1 
however,  has  conclusively  proved  that  the  blood  of  any  of  the  lower 
animals  has  a  most  injurious  effect  on  the  human  red  corpuscles,  which 
rapidly  become  swollen  and  decolorized,  and  discharge  their  coloring 
matter  into  the  serum.  It  is  certain,  therefore,  that  this  plan  cannot 
be  adopted  in  practice. 

The  great  practical  difficulty  in  transfusion  has  always  been  the 
coagulation  of  the  blood  very  shortly  after  it  has  been  removed  from 
the  body.  When  fresh-drawn  blood  is  exposed  to  the  atmosphere,  the 
fibrin  commences  to  solidify  rapidly,  generally  in  from  three  to  four 
minutes,  sometimes  much  sooner.  •  It  is  obvious  that  the  moment 
fibrillation  has  commenced,  the  blood  is,  ipso  facto,  unfitted  for  trans- 
fusion, not  only  because  it  can  be  no  longer  passed  readily  through  the 
injecting  apparatus,  but  because  of  the  great  danger  of  propelling  small 
masses  of  fibrin  into  the  circulation,  and  thus  causing  embolism. 
Hence,  if  no  attempt  be  made  to  prevent  this  difficulty,  it  is  essential, 
no  matter  what  apparatus  is  used,  to  hurry  on  the  operation  so  as  to 
inject  before  fibrination  has  begun.  This  is  a  fatal  objection,  for  there 
is  no  operation  in  the  whole  range  of  surgery  in  which  calmness  and 
deliberation  are  so  essential,  the  more  so  as  the  surroundings  of  the 
patient  in  these  unfortunate  cases  are  such  as  to  tax  the  presence 
of  mind  and  coolness  of  the  practitioner  and  his  assistants  to  the 
utmost. 

All  the  recent  improvements  have  had  for  their  object  the  avoidance 
of  coagulation,  and  practically  this  has  been  effected  in  one  of  three 
ways :  First,  by  immediate  transfusion  from  arm  to  arm,  without 
allowing  the  blood  to  be  exposed  to  the  atmosphere,  according  to  the 
methods  proposed  by  Aveling,  Roussel,  and  Schafer.  Second,  by  add- 
ing to  the  blood  certain  chemical  reagents  which  have  the  property  of 
preventing  coagulation.  Third,  removal  of  the  fibrin  entirely  by 
promoting  its  coagulation  and  straining  the  blood,  so  that  the  liquor 
sanguinis  and  blood  corpuscles  alone  are  injected. 

Inasmuch  as  the  success  of  the  operation  altogether  depends  on  the 
method  adopted,  it  will  be  well,  before  going  further,  to  consider  briefly 
the  advantages  and  disadvantages  of  each  of  these  plans. 

Aveling's  Method. — The  method  of  immediate  transfusion  has 
been  brought  prominently  before  the  profession  by  Dr.  Aveling,  who 
has  invented  an  ingenious  apparatus  for  performing  it.  The  apparatus 
consists  essentially  of  a  miniature  Higginson's  syringe,  without  valves, 
and  with  a  small  silver  canula  at  either  end.  One  canula  is  inserted 
into  the  vein  of  the  person  supplying  blood,  the  other  into  a  vein  of 
the  patient,  and  by  a  curious  manipulation  of  the  syringe,  subsequently 

*  Die  Transfusion  des  Blutes,  Leipzig,  1875. 


THE    TRANSFUSION    OF    BLOOD.  567 

to  be  described,  the  blood  is  carried  from  one  vein  into  the  other.  It 
must  be  admitted  that  if  there  were  no  practical  difficulties,  this  instru- 
ment would  be  admirable,  and  it  is,  therefore,  not  surprising  that  it 
should  have  met  with  so  much  favor  from  the  profession.  I  cannot 
but  think,  however,  that  the  operation  is  not  so  simple  as  at  first  sight 
appears,  and  that  therefore  it  wants  one  of  the  essential  elements 
required  in  any  procedure  for  performing  transfusion.  One  of  my 
objections  is,  that  it  is  by  no  means  easy  to  work  the  apparatus  without 
considerable  practice.  Of  this  I  have  satisfied  myself  by  asking  mem- 
bers of  my  class  to  work  it  after  reading  the  printed  directions,  and 
finding  that  they  are  not  always  able  to  do  so  at  once.  Of  course,  it 
may  be  said  that  it  is  easy  to  acquire  the  necessary  manipulative  skill ; 
but  when  the  necessity  for  transfusion  arises,  there  is  not  time  left  for 
practising  with  the  instrument,  and  it  is  essential  that  an  apparatus, 
to  be  universally  applicable,  should  be  capable  of  being  used  imme- 
diately and  without  previous  experience.  Other  objections  are — the 
necessity  of  several  assistants,  the  uncertainty  of  there  being  a  sufficient 
circulation  of  blood  in  the  veins  of  the  donor  to  afford  a  constant 
supply,  and  the  possibility  of  the  whole  apparatus  being  disturbed  by 
restlessness  or  jactitation  on  the  part  of  the  patient.  For  these  reasons 
it  seems  to  me  that  this  plan  of  immediate  transfusion  is  not  so  simple, 
nor  so  generally  applicable,  as  defibrination.  Still,  it  is  impossible  not 
to  recognize  its  merits,  and  it  is  certainly  well  worthy  of  further  study 
and  investigation. 

Roussel's  Method. — Another  method  of  immediate  transfusion  is 
that  recommended  by  Roussel,1  whose  apparatus  has  recently  attracted 
considerable  attention.  It  possesses  many  undoubted  advantages,  and 
is  beyond  doubt  a  valuable  addition  to  our  means  of  performing  the 
operation.  It  has,  however,  the  great  disadvantage  of  being  costly 
and  complicated,  and  hence  I  do  not  believe  that  it  is  likely  to  come 
into  general  use. 

Schafer's  Method. — The  third  method  is  that  recommended  by  Dr. 
Schafer  in  his  recent  excellent  reports  on  transfusion  submitted  to  the 
Obstetrical  Society.2  Schafer  suggests  two  methods  of  performing  the 
operation  :  one  from  vein  to  vein,  the  other  from  artery  to  artery. 
The  latter,  he  holds,  has  the  advantage  of  supplying  pure  oxygenated 
blood,  under  the  best  possible  conditions  for  securing  the  amelioration 
of  a  patient  suffering  from  the  effects  of  profuse  hemorrhage.  The 
necessary  operative  proceedings  are,  however,  somewhat  complicated, 
and  it  seems  to  me  very  doubtful  if  this  plan  is  likely  to  be  at  all 
commonly  used.  His  method  of  immediate  transfusion,  however,  is 
very  simple,  and  is  well  worthy  of  trial.  In  his  experiments  on  the 
lower  animals  it  answered  admirably.  I  am  not'aware  that  it  has  yet 
been  tried  on  the  human  subject,  but  I  do  not  see  any  practical  diffi- 
culty in  its  application.  For  the  description  of  the  operation  I  have 
inserted  Dr.  Schafer's  own  directions  for  the  performance  of  venous 
immediate  transfusion. 

The  second  plan  for  obviating  the  bad  effects  of  clotting  is  the  addi- 

1  Obstetrical  Transactions  for  18T6,  vol.  xviii.  p.  280. 
*  Ibid.,  vol.  xxi.  p.  316. 


568  OBSTETRIC    OPERATIOXS. 

tion  of  some  substance  to  the  blood  which  shall  prevent  coagulation. 
It  is  well  known  that  several  salts  have  this  property,  and  the  experi- 
ments made  in  the  case  of  cholera  patients  prove  that  solutions  of  some 
of  them  may  be  injected  into  the  venous  system  without  injury.  This 
method  has  been  specially  advocated  by  Dr.  Braxton  Hicks,  Avho  uses 
a  solution  of  three  ounces  of  fresh  phosphate  of  soda  in  a  pint  of  water, 
about  six  ounces  of  which  are  added  to  the  quantity  of  blood  to  be 
injected.  He  has  narrated  four  cases l  in  which  this  plan  was  adopted 
successfully,  so  far  as  the  prevention  of  coagulation  was  concerned.  It 
certainly  enables  the  operation  to  be  performed  with  deliberation  and 
care,  but  it  is  somewhat  complicated,  and  it  may  often  happen  that 
the  necessary  chemicals  are  not  at  hand.  A  further  objection  is  the 
bulk  of  fluid  which  must  be  injected,  and  there  is  reason  to  believe 
that  this  has  in  some  cases  seriously  embarrassed  the  heart's  action 
and  interfered  with  the  success  of  the  operation.  In  many  of  the 
successful  cases  of  transfusion  the  amount  of  blood  injected  has  been 
very  small,  not  more  than  two  ounces.  Dr.  Richardson  proposes  to 
prevent  coagulation  by  the  addition  of  liquor  ammonite  to  the  blood, 
in  the  proportion  of  two  minims  diluted  with  twenty  minims  of  water 
to  each  ounce  of  blood. 

Defibrination  of  the  Blood. — The  last  method,  and  the  one  which, 
on  the  whole,  I  believe  to  be  the  simplest  and  most  effectual,  is  defibrina- 
tion.  It  has  been  chiefly  practised  in  the  British  Isles  by  Dr.  McDon- 
nell, of  Dublin,  who  has  published  several  very  interesting  cases  in 
which  he  employed  it,  and  on  the  Continent  by  Martin,  of  Berlin,  and 
De  Belina,  of  Paris.  The  process  of  removing  the  fibrin  is  simple  in 
the  extreme,  and  occupies  a  few  minutes  only.  Another  advantage  is 
that  the  blood  to  be  transfused  may  be  prepared  quietly  in  an  adjoining 
apartment,  so  that  the  operation  may  be  performed  with  the  greatest 
calmness  and  deliberation,  and  the  donor  is  spared  the  excitement  and 
distress  which  the  sight  of  the  apparently  moribund  patient  is  apt  to 
cause,  and  which,  as  Dr.  Hicks  has  truly  pointed  out,  may  interfere  with 
the  free  flow  of  blood.  The  researches  of  Panum,  Brown-Sequard,  and 
others  have  proved  that  the  blood  corpuscles  are  the  true  vivifying 
element,  and  that  defibrinated  blood  acts  as  well  in  every  respect  as  that 
containing  fibrin.  It  has  been  proved  that  the  fibrin  is  reproduced  within 
a  short  time,2  and  the  whole  tendency  of  modern  research  is  to  regard 
it,  not  as  an  essential  element  of  the  blood,  but  as  an  excrementitions 
product,  resulting  from  the  degradation  of  tissue,  which  may,  therefore,  be 
advantageously  removed.  Another  advantage  derived  from  defibrina- 
tion  is,  that  the  corpuscles  are  freely  exposed  to  the  atmosphere,  oxygen 
is  taken  up,  and  carbonic  acid  given  off,  and  the  dangers  which  Brown- 
Sequard  has  shown  to  arise  from  the  use  of  blood  containing  too  much 
carbonic  acid  are  thereby  avoided.  There  can  be,  therefore,  no  physi- 
ological objection  to  the  removal  of  the  fibrin,  which,  moreover,  takes 
away  all  practical  difficulty  from  the  operation.  The  straining  to 
which  the  defibrinated  blood  is  subjected  entirely  prevents  the  possi- 
bility of  even  the  most  minute  particle  of  fibrin  being  contained  in  the 

1  Guy's  Hospital  Reports.  1ST>9,  vol.  xiv.,  3J  series,  p.  1. 

2  Panum:  virchow's  Arch.,  vol.  xxvii. 


THE    TRANSFUSION    OF    BLOOD.  569 

injected  fluid ;  the  risk  from  embolism  is,  therefore,  less  than  in  any 
of  the  other  processes  already  referred  to.  My  own  experience  of  this 
plan  is  limited  to  three  cases,  but  in  two  it  answered  so  well  that  I  can 
conceive  no  reasonable  objection  to  it.  I  should  be  inclined  to  say  that 
transfusion,  thus  performed,  is  amongst  the  simplest  of  surgical  oper- 
ations— an  opinion  which  the  experience  of  McDonnell  and  others 
fully  confirms. 

Transfusion  of  Milk. — Recently  the  intra-venous  injection  of 
freshly -drawn  warm  milk  has  been  recommended  as  a  substitute  for 
blood,  chiefly  in  America.  It  was  first  used  by  Dr.  Hodder,  of 
Toronto,  but  has  been  introduced  and  strongly  advocated  by  Thomas, 
of  New  York,  who  has  used  it  twice  after  ovariotomy.  Brown-Sequard, 
in  experimenting  on  the  lower  animals,  found  that  it  answered  as  well 
as  either  fresh  or  defibrinated  blood,  and  about  half  an  hour  after  the 
injection  no  trace  of  the  milk  corpuscles  could  be  found  in  the  blood. 
Schiifer,  however,  found  that  the  action  of  milk  on  the  blood  corpuscles 
was  highly  deleterious,  and  that  it  introduces  the  germs  of  septic 
organisms  likely  to  produce  very  serious  results.  He,  therefore,  pro- 
nounces strongly  against  its  use. 

Injection  of  Saline  Solutions. — Dr.  William  Hunter1  has  recently 
published  a  series  of  valuable  observations  on  the  subject  of  transfusion. 
His  conclusions  are  that  its  principal  effects  are  those  of  stimulation, 
and  that,  for  all  practical  purposes,  in  cases  of  severe  hemorrhage,  the 
injection  of  a  saline  solution  is  quite  as  efficacious,  and  much  simpler. 
For  this  purpose  all  that  is  required  is  a  glass  canula,  such  as  Schafer's, 
a  piece  of  India-rubber  tubing,  and  a  syringe,  all  of  which  should  be, 
of  course,  carefully  asepticized.  The  fluid  to  be  injected  is  very  readily 
manufactured  by  dissolving  a  teaspoouful  of  common  salt  in  a  pint  of 
water  at  a  temperature  of  1 00°.  It  has  been  suggested2  that  the  injec- 
tion of  the  same  solution  into  the  muscular  tissues  will  answer  equally 
well.  For  this  purpose  the  needle  of  an  aspirator  is  attached  by  a 
piece  of  India-rubber  tubing  to  an  ordinary  glass  funnel.  The  needle 
is  inserted  into  the  gluteal  region  or  loins,  and  the  saline  infusion 
poured  into  the  funnel.  After  it  has  entered  the  tissues  it  is  diffused 
by  massage.  Both  these  methods  have  the  great  advantage  of  sim- 
plicity, and,  if  further  experience  proves  them  to  be  as  efficacious  as 
ll icy  are  said  to  be,  will  prove  valuable  in  many  cases  in  which  the 
transfusion  of  blood  cannot  be  employed. 

Statistical  Results. — The  number  of  cases  of  transfusion  are  per- 
haps not  sufficient  to  admit  of  completely  reliable  conclusions.  It  is 
certain,  however,  that  transfusion  has  often  been  the  means  of  rescuing 
the  patient  when  apparently  at  the  point  of  death,  and  after  all  other 
means  of  treatment  had  failed.  Professor  Martin  records  57  cases,  in 
43  of  which  transfusion  was  completely  successful,  and  in  7  tem- 
porarily so;  while  in  the  remaining  7  no  reaction  took  place.  Dr. 
Iliirginson,  of  Liverpool,  has  had  15  cases,  10  of  which  were  suc- 
cessful. Figures  such  as  these  are  encouraging,  and  they  are  sufficient 
to  prove  that  the  operation  is  one  which  at  least  offers  a  fair  hope  of 

i  Brit.  Med.  Journ.,  vol.  ii.,  1889. 

8  Miinchmeyer:  Arch.  fiirGynak.,  Brt.  xxxiv.  Hft.  3. 


570  OBSTETRIC    OPERATIONS. 

success,  and  which  no  obstetrician  would  be  justified  in  neglecting, 
when  the  patient  is  sinking  from  the  exhaustion  of  profuse  hemor- 
rhage. It  is  to  be  hoped  also  that  further  experience  may  prove  it  to 
be  of  value  in  other  cases  in  which  its  use  has  been  suggested,  but  not, 
as  yet,  put  to  the  test  of  experiment. 

Possible  Dangers  of  the  Operation. — The  possible  risks  of  the 
operation  would  seem  to  be  the  danger  of  injecting  minute  particles  of 
fibrin  which  form  emboli ;  of  bubbles  of  air ;  or  of  overwhelming  the 
action  of  the  heart  by  injecting  too  rapidly,  or  in  too  great  quantity. 
These  may  be,  to  a  great  extent,  prevented  by  careful  attention  to  the 
proper  performance  of  the  operation,  and  it  does  not  clearly  appear, 
from  the  recorded  cases,  that  they  have  ever  proved  fatal.  We  must 
also  bear  in  mind  that  transfusion  is  seldom  or  never  likely  to  be 
attempted  until  the  patient  is  in  a  state  which  would  otherwise  almost 
certainly  preclude  the  hope  of  recovery,  and  in  which,  therefore,  much 
more  hazardous  proceedings  would  be  fully  justified. 

Cases  Suitable  for  Transfusion. — The  cases  suitable  for  trans- 
fusion are  those  in  which  the  patient  is  reduced  to  an  extreme  state  of 
exhaustion  from  hemorrhage  during  or  after  labor  or  miscarriage, 
whether  by  the  repeated  losses  of  placenta  prsevia,  or  the  more  sudden 
and  profuse  flooding  of  post-partum  hemorrhage.  The  operation  will 
not  be  contemplated  until  other  and  simpler  means  have  been  tried  and 
failed,  or  until  the  symptoms  indicate  that  life  is  on  the  verge  of  ex- 
tinction. If  the  patient  should  be  deadly  pale  and  cold,  with  no  pulse 
at  the  wrist,  or  one  that  is  scarcely  perceptible ;  if  she  be  unable  to 
swallow,  or  vomits  incessantly ;  if  she  lie  in  an  unconscious  state ;  if 
jactitation,  or  convulsions,  or  repeated  faintings  should  occur ;  if  the 
respiration  be  laborious,  or  very  rapid  and  sighing ;  if  the  pupils  do 
not  act  under  the  influence  of  light,  it  is  evident  that  she  is  in  a  condi- 
tion of  extreme  danger,  and  it  is  under  such  circumstances  that  trans- 
fusion, performed  sufficiently  soon,  offers  a  fair  prospect  of  success.  It 
does  not  necessarily  follow  because  one  or  other  of  these  symptoms  is 
present  that  there  is  no  chance  of  recovery  under  ordinary  treatment, 
and,  indeed,  it  is  within  the  experience  of  all  that  patients  have  rallied 
under  apparently  the  most  hopeless  conditions.  But  when  several  of 
them  occur  together,  the  prospect  of  recovery  is  much  diminished,  and 
transfusion  would  then  be  fully  justified,  especially  as  there  is  no  reason 
to  think  that  a  fatal  result  has  ever  been  directly  traced  to  its  employ- 
ment. Indeed,  like  most  other  obstetric  operations,  it  is  more  likely 
to  be  postponed  until  too  late  to  be  of  good  service,  than  to  be  employed 
too  early ;  and  in  some  of  the  cases  reported  as  unsuccessful  it  was 
not  performed  until  respiration  had  ceased  and  death  had  actually 
taken  place.  It  has  sometimes  been  said  that  transfusion  should  never 
be  employed  if  the  uterus  be  not  firmly  contracted,  so  as  to  prevent  the 
injected  blood  again  escaping  through  the  uterine  sinuses.  The  cases 
in  which  this  is  likely  to  occur  are  few  ;  and  if  one  were  met  with,  the 
escape  of  blood  could  be  prevented  by  the  injection  into  the  uterus  of 
the  perchloride  of  iron. 

Description  of  the  Operation. — In  describing  the  operation  I 
shall  limit  myself  to  an  account  of  Aveling's  and  Schafer's  method  of 


THE    TRANSFUSION    OF    BLOOD.  571 

immediate  transfusion,  and  to  that  of  injecting  defibrinated  blood.  I 
consider  myself  justified  in  omitting  any  account  of  the  numerous  in- 
struments which  have  been  invented  for  the  purpose  of  injecting  pure 
blood,  since  I  believe  the  practical  difficulties  are  too  great  ever  to 
render  this  form  of  operation  serviceable.  The  great  objection  to 
most  of  them  is  their  cost  and  complexity  ;  and  as  long  as  any  special 
apparatus  is  considered  essential,  the  full  benefits  to  be  derived  from 
transfusion  are  not  likely  to  be  realized.  The  necessity  for  employing 
it  arises  suddenly  ;  it  may  be  in  a  locality  in  which  it  is  impossible  to 
procure  a  special  instrument;  and  it  would  be  well  if  it  were  under- 
stood that  transfusion  may  be  safely  and  effectually  performed  by  the 
simplest  means.  In  many  of  the  successful  cases  an  ordinary  syringe 
was  used;  in  one,  in  the  absence  of  other  instruments,  a  child's  toy 
syringe  Avas  employed.  I  have  myself  performed  it  with  a  simple 
syringe  purchased  at  the  nearest  chemist's  shop,  when  a  special  trans- 
fusion apparatus  failed  to  act  satisfactorily. 


FIG.  204. 


D  Y       • 

<.       D 

Method  of  transfusion  by  Aveling's  apparatus. 

In  immediate  transfusion  (Fig.  204),  the  donor  is  seated  close  to 
the  patient,  and  the  veins  in  the  arms  of  each  having  been  opened, 
the  silver  canula  at  either  end  of  the  instrument  is  introduced  into 
them  (A  B).  The  tube  between  the  bulb  and  the  donor  is  now  pinched 
(D),  so  as  to  form  a  vacuum,  and  the  bulb  becomes  filled  with  blood 
from  the  donor.  The  finger  is  now  removed  so  as  to  compress  the 
distal  tube  (D'),  and  the  bulb  being  compressed  (c),  its  contents  are 
injected  into  the  patient's  vein.  The  bulb  is  calculated  to  hold 
about  two  drachms,  so  that  the  amount  injected  can  be  estimated  by 
the  number  of  times  it  is  emptied.  The  risk  of  injecting  air  is  pre- 
vented by  filling  the  syringe  with  water  which  is  injected  before  the 
blood. 

SCHAFER'S  DIRECTIONS  FOR  IMMEDIATE  TRAI-SFUSION. 

Direct  Venous  Transfusion. — "  Procure  two  glass  canulas  of  appro- 
priate size  and  shape  (see  Fig.  205),  and  a  piece  of  black  India-rubber 


572  OBSTETRIC    OPERATIONS. 

tubing,  seven  inches  long,  and  not  less  than  a  quarter  of  an  inch  bore, 
fitted  to  the  canulas.     This  apparatus  could  always  be  improvised. 

"Place  the  transfusion-tube  in  a  basin  of  hot  water  containing  a 
little  carbonate  of  soda.  Put  a  tape  around  the  arm  of  the  patient 
just  below  the  place  where  the  vein  is  to  be  opened,  and  another  just 
above.  Expose  the  vein  by  an  incision  through  the  skin,  which  should 
be  made  transversely  if  the  position  of  the  vein  cannot  be  made  out 
through  the  skin.  Clear  a  small  piece  of  the  vein  with  forceps,  and 
slip  a  pointed  piece  of  card  underneath  it.  By  a  snip  with  scissors 
make  an  oblique  opening  into  the  vein,  and  partly  insert  a  small 
blunt  instrument  (such  as  a  wool-needle)  so  that  the  aperture  is  not 
lost.  Remove  the  upper  tape.  Next  prepare  the  vein  of  the  giver. 
To  do  this  put  tapes  around  the  arm  just  below  and  above  the  place 
where  the  vein  is  to  be  opened.  Expose  the  vein  by  a  longitudinal 
incision  through  the  skin.  Clear  a  small  piece  of  the 
vessel  with  forceps  and  pass  a  thread  ligature  under- 
neath. A  slip  of  card  may  also  be  placed  under  this 
vein.  Make  a  snip  into  the  vein  just  above  the  liga- 
ture, and  then,  taking  the  transfusion-tube  out  of  the 
soda  solution,  slip  one  of  the  canulas  into  the  vein 
of  the  giver,  and  tie  it  in  with  a  simple  knot,  which 
can  be  readily  untied.  Let  the  giver  go  to  the  bed- 
side and  place  his  arm  alongside  that  of  the  patient. 
Hold  the  end  of  the  India-rubber  tube  with  the 
second  canula  up  a  little,  and  release  the  lower  tape 
on  the  arm  of  the  blood -giver.  As  soon  as  blood 
flows  out  of  the  second  canula  pinch  the  India-rubber 
tube  close  to  the  canula,  so  as  to  stop  the  flow,  and, 
removing  the  wool-needle,  slip  the  end  of  the  canula 
into  the  vein  of  the  patient,  hold  it  there,  and  allow  the  blood  to  pass 
freely  along  the  tube.  Three  minutes  will  generally  be  long  enough 
for  the  flow,  which  can  be  stopped  by  compressing  the  vein  of  the 
giver  below  the  canula.  Both  canulas  may  now  be  withdrawn  and 
the  ligature  removed  from  the  vein  of  the  giver,  the  cut  veins  being 
dealt  with  in  the  usual  way.  Of  course,  the  other  tape  on  the  arm  of 
the  donor  must  be  removed  as  soon  as  the  transfusion  is  over. 

"  Instead  of  using  the  transfusion-tube  empty,  it  may  be  filled  with 
soda  solution,  to  the  exclusion  of  air.  It  is  necessary  to  have  one  or 
two  spring  clips  on  the  tube  to  prevent  the  escape  of  the  solution. 
This  is  a  much  better  plan  than  the  other,  for  the  blood  need  not  be 
allowed  to  flow  into  the  tube  until  the  second  canula  is  inserted,  and 
then,  by  opening  the  clips,  it  may  drive  the  soda  solution  before  it 
into  the  vein.  The  small  quantity  of  carbonate  of  soda  solution  neces- 
sary to  fill  the  simple  tube  will  do  the  patient  no  harm." 

Injection  of  Defibrinated  Blood. — For  injecting  defibrinated  blood 
various  contrivances  have  been  used.  McDonnell's  instrument  is 
a  simple  cylinder  with  a  nozzle  attached,  from  which  the  blood  is 
propelled  by  gravitation.  When  the  propulsive  power  is  insufficient, 
increased  pressure  is  applied  by  breathing  forcibly  into  the  open  end 
of  the  receiver.  De  Belina's  instrument  is  on  the  same  principle, 


THE    TRANSFUSION    OF    BLOOD.  573 

only  atmospheric  pressure  is  supplied  by  a  contrivance  similar  to 
Richardson's  spray-producer,  attached  to  one  end.  The  idea  is  simple, 
but  there  is  some  doubt  of  a  gravitation  instrument  being  sufficiently 
powerful,  and  it  certainly  failed  in  my  hands.  I  have  had  the  valves 
applied  to  Aveling's  instrument,  so  that  it  works  by  compression  of 
the  bulb,  like  an  ordinary  Higginson's  syringe.  This,  with  a  single 
silver  canula  at  one  end  for  introduction  into  the  vein,  forms  a  per- 
fect and  inexpensive  transfusion  apparatus,  taking  up  little  space.  If 
it  be  not  at  hand,  any  small  syringe  with  a  fine  nozzle  may  be  used. 

The  first  step  of  the  operation  is  defibrination  of  the  blood,  which 
should,  if  possible,  be  prepared  in  an  apartment  adjoining  the  patient's. 
The  blood  should  be  taken  from  the  arm  of  a  strong  and  healthy 
man.  The  quality  cannot  be  unimportant,  and  in  some  recorded 
cases  the  failure  of  the  operation  has  been  attributed  to  the  fact  of  the 
donor  having  been  a  weakly  female.  The  supply  from  a  woman 
might  also  prove  insufficient ;  and,  although  it  has  been  shown  that 
blood  from  two  or  more  persons  may  be  used  with  safety,  yet  such  a 
change  necessarily  causes  delay,  and  should,  if  possible,  be  avoided. 
A  vein  having  been  opened,  eight  or  ten  ounces  of  blood  are  with- 
drawn and  received  into  some  perfectly  clean  vessel,  such  as  a  finger- 
bowl.  As  it  flows  it  should  be  briskly  agitated  with  a  clean  silver 
fork  or  a  glass  rod,  and  very  shortly  strings  of  fibrin  begin  to  form. 
It  is  now  strained  through  a  piece  of  fine  muslin,  previously  dipped 
in  hot  water,  into  a  second  vessel  which  is  floating  in  water  at  a  tem- 
perature of  about  105°.  By  this  straining,  the  fibrin  and  all  air- 
bubbles  resulting  from  the  agitation  are  removed ;  if  in  no  excessive 
hurry,  straining  may  be  done  a  second  time.  If  the  vessel  be  kept 
floating  in  warm  water,  the  blood  is  prevented  from  getting  cool,  and 
we  can  now  proceed  to  prepare  the  arm  of  the  patient  for  injection. 

This  is  the  most  delicate  and  difficult  part  of  the  operation,  since 
the  veins  are  generally  collapsed  and  empty,  and  by  no  means  easy  to 
find.  The  best  way  of  exposing  them  is  that  practised  by  McDonnell, 
who  pinches  up  a  fold  of  the  skin  at  the  bend  of  the  elbow,  and  trans- 
fixes it  with  a  fine  tenotomy  knife  or  scalpel,  so  making  a  gaping 
wound  in  the  integument,  at  the  bottom  of  which  they  are  seen  lying. 
A  probe  should  now  be  passed  underneath  the  vein  selected  for  open- 
ing, so  as  to  avoid  the  chance  of  its  being  lost  at  any  subsequent  stage 
of  the  operation.  This  is  a  point  of  some  importance,  and  from  the 
neglect  of  this  precaution  I  have  been  obliged  to  open  another  vein 
than  that  originally  fixed  on.  A  small  portion  of  the  vein  being 
raised  with  the  forceps,  a  nick  is  made  into  it  for  the  canula. 

Injection  of  the  Blood. — The  prepared  blood  is  now  brought  to  the 
bedside,  and  the  apparatus  having  been  previously  filled  with  blood  to 
avoid  the  risk  of  injecting  any  bubbles  of  air,  the  canula  is  inserted  into 
the  opening  made  in  the  vein,  and  transfusion  commenced.  It  should  be 
constantly  borne  in  mind  that  this  part  of  the  operation  should  be  con- 
ducted with  the  greatest  caution,  the  blood  introduced  very  slowly,  and 
the  effect  on  the  patient  carefully  watched.  The  injection  may  be  pro- 
ceeded with  until  some  perceptible  effect  is  produced,  which  will  gener- 
ally be  a  return  of  the  pulsation,  first  at  the  heart  and  subsequently  at 


574  OBSTETRIC    OPERATIONS. 

the  wrist,  an  increase  in  the  temperature  of  the  body,  greater  depth  and 
frequency  of  the  respirations,  and  a  general  appearance  of  returning 
animation  about  the  countenance.  Sometimes  the  arms  have  been 
thrown  about,  or  spasmodic  twitchings  of  the  face  have  taken  place. 
The  quantity  of  blood  required  to  produce  these  effects  varies  greatly, 
but  in  the  majority  of  cases  has  been  very  small.  Occasionally  two 
ounces  have  proved  sufficient,  and  the  average  may  be  taken  as  ranging 
between  four  and  six ;  although  in  a  few  cases  between  ten  and  twenty 
have  been  used.  The  practical  rule  is  to  proceed  very  slowly  with  the 
injection  until  some  perceptible  result  is  observed.  Should  embarrassed 
or  frequent  respiration  supervene,  we  may  suspect  that  we  have  been 
injecting  either  too  great  a  quantity  of  blood,  or  with  too  mucn  force 
and  rapidity,  and  should  desist  until  the  suspicious  symptoms  pass 
away.  It  may  happen  that  the  effects  of  the  transfusion  have  been 
highly  satisfactory,  but  that  in  the  course  of  time  there  is  evidence  of 
returning  syncope.  This  may  possibly  be  prevented  by  the  adminis- 
tration of  stimulants,  but  if  these  fail  there  is  no  reason  why  a  fresh 
supply  of  blood  should  not  again  be  injected,  but  this  should  be  done 
before  the  effects  of  the  first  transfusion  have  entirely  passed  away. 

Secondary  Effects  of  Transfusion. — The  subsequent  effects  in 
successful  cases  of  transfusion  merit  careful  study.  In  some  few  cases 
death  is  said  to  have  happened  within  a  few  weeks,  with  symptoms 
resembling  pyamia.  Too  little  is  known  on  this  point,  however,  to 
justify  any  positive  conclusions  with  regard  to  it. 

[Transfusion  with  defibrinated  blood  was,  I  believe,  first  tried  in 
America  by  Dr.  Joshua  G.  Allen,  of  Philadelphia,  on  December  30, 
1868,  on  a  woman  who  suffered  from  the  effects  of  repeated  attacks  of 
uterine  hemorrhage.  Six  fluidounces  were  injected,  and  the  patient 
recovered  a  reasonable  degree  of  health.  In  1869,  Dr.  Allen  repeated 
the  operation  four  times,  in  two  of  the  cases  being  associated  with  Dr. 
Thomas  G.  Morton  at  the  Pennsylvania  Hospital,  and  using  a  double 
vessel  for  keeping  the  blood  warm,  consisting  of  a  conical  cup  for  hold- 
ing the  blood  and  a  lower  vessel  for  containing  warm  water,  the  two 
being  made  in  one  and  the  temperature  ascertained  by  an  outside  ther- 
mometer. Dr.  Morton  repeated  the  experiment  on  two  other  patients 
in  1870  and  1874,  the  second,  a  girl  of  eleven,  being  operated  on  twice, 
at  intervals  of  six.  weeks,  for  bleeding  from  the  nose  and  bladder,  the 
effect  of  purpura;  she  entirely  recovered.  Dr.  M.  used  a  set  of  instru- 
ments specially  designed  for  the  work,  and  shown  in  illustration  in  the 
Amer.Journ.ofthe  Med.  Sciences,  July,1874,p.  112.  Between  1874and 
1886  he  repeated  the  operation  on  several  hospital  and  private  patients. 

Intra-venous  saline  injections  are  far  more  readily  used,  are  safer, 
and  are  believed  from  the  tests  that  have  been  made  to  be  quite  as  effi- 
cacious as  blood.  What  has  been  called  artificial  serum  consists  of  20 
grammes  of  sulphate  of  soda  and  10  grammes  of  chloride  of  sodium  in  2 
litres  of  water.  The  solution  should  be  injected  into  a  large  vein  slowly 
and  in  large  quantity,  as  much  as  a  pint  or  more  at  a  time,  and  repeated 
at  intervals ;  the  fluid  should  be  blood-warm.  Another  formula  consists 
of  pure  common  salt  1J  fluidraehms,  liquor  potassa3  1  minim,  and 
pure  carbonate  of  potash  45  grains  in  two  quarts  of  water. — ED.] 


PART  Y. 

THE  PUERPERAL  STATE. 


CHAPTER    I. 

THE  PUERPERAL   STATE   AND   ITS   MANAGEMENT. 

Importance  of  Studying  the  Puerperal  State. — The  key  to  the 
management  of  women  after  labor,  and  to  the  proper  understanding  of 
the  many  important  diseases  which  may  then  occur,  is  to  be  found  in 
a  study  of  the  phenomena  following  delivery,  and  of  the  changes  going 
on  in  the  mother's  system  during  the  puerperal  period.  No  doubt 
natural  labor  is  a  physiological  and  healthy  function,  and  during 
recovery  from  its  effects  disease  should  not  occur.  It  must  not  be  for- 
gotten, however,  that  none  of  our  patients  are  under  physiologically 
healthy  conditions.  The  surroundings  of  the  lying-in  woman,  the 
eifects  of  civilization,  of  errors  of  diet,  of  defective  cleanliness,  of 
exposure  to  contagion,  and  of  a  hundred  other  conditions  which  it  is 
impossible  to  appreciate,  have  most  important  influences  on  the  results 
of  childbirth.  Hence  it  follows  that  labor,  even  under  the  most  favor- 
able conditions,  is  attended  with  considerable  risk 

The  Mortality  of  Childbirth. — It  is  not  easy  to  say  with  accuracy 
what  is  the  precise  mortality  accompanying  childbirth  in  ordinary 
domestic  practice,  since  the  returns  derived  from  the  reports  of  the 
Registrar-General,  or  from  private  sources,  are  manifestly  open  to  seri- 
ous error.  The  nearest  approach  to  a  reliable  estimate  is  that  made 
by  the  late  Dr.  Matthews  Duncan,1  wrho  calculated,  from  figures  derived 
from  various  sources,  that  no  fewer  than  1  out  of  every  120  women, 
delivered  at  or  near  the  full  time,  died  within  four  weeks  of  childbirth. 
This  indicates  a  mortality  far  above  that  which  has  been  generally 
believed  to  accompany  childbearing  under  favorable  circumstances. 
It,  however,  closely  approximates  to  a  similar  estimate  made  by  Mc- 
Clintock,2  who  calculated  the  mortality  in  England  and  Wales  as  1  in 
126  ;  and  in  the  upper  and  middle  classes  alone,  where  the  conditions 
may  naturally  be  supposed  to  be  more  favorable,  at  1  in  146  ;  more 
recently  he  had  come  to  the  conclusion  from  his  own  increased  experi- 
ence, and  the  published  results  of  the  practice  of  others,  that  1  in  100 
would  more  correctly  represent  the  rate  of  puerperal  mortality.3  In 


1  The  "  Mortality  of  Childbed,"  Edin.  Med.  .Tourn.,  vol.  1869-70,  p.  399. 

2  Dublin  Quarterly  Journ.  of  Med.  Science,  1869,  vol.  xlviii.  p.  l>56. 
»  Brit.  Med.  Journ.,  1878,  vol.  ii.  p.  216. 


(575) 


576  THE    PUERPERAL    STATE. 

these  calculations  there  are  some  obvious  sources  of  error,  since  they 
include  deaths  from  all  causes  within  four  weeks  of  delivery,  some  of 
which  must  have  been  independent  of  the  puerperal  state. 

But  it  is  not  the  deaths  alone  which  should  be  considered.  All 
practitioners  know  how  large  a  number  of  their  patients  suffer  from 
morbid  states  which  may  be  directly  traced  to  the  effects  of  childbear- 
ing.  It  is  impossible  to  arrive  at  any  statistical  conclusion  on  this 
point,  but  it  must  have  a  very  sensible  and  important  influence  on  the 
health  of  childbeariug  women. 

Alterations  in  the  Blood  after  Delivery. — The  state  of  the  blood 
during  pregnancy,  already  referred  to  (p.  145),  has  an  important  bear- 
ing on  the  puerperal  state.  There  is  hyperinosis,  which  is  largely 
increased  by  the  changes  going  on  immediately  after  the  birth  of  the 
child ;  for  then  the  large  supply  of  blood  which  has  been  going  to  the 
uterus  is  suddenly  stopped,  and  the  system  must  also  get  rid  of  a 
quantity  of  effete  matter  thrown  into  the  circulation,  in  consequence  of 
the  degenerative  changes  occurring  in  the  muscular  fibres  of  the  uterus. 
Hence  all  the  depurative  channels  by  which  this  can  be  eliminated 
are  called  on  to  act  with  great  energy.  If,  in  addition,  the  peculiar 
condition  of  the  generative  tract  be  borne  in  mind — viz.,  the  large  open 
vessels  on  its  inner  surface,  the  partially  bared  inner  surface  of  the 
uterus,  and  the  channels  for  absorption  existing  in  consequence  of 
slight  lacerations  in  the  cervix  or  vagina — it  is  not  a  matter  of  surprise 
that  septic  diseases  should  be  so  common. 

It  will  be  well  to  consider  successively  the  various  changes  going 
on  after  delivery,  and  then  we  shall  be  in  a  better  position  for  study- 
ing the  rational  management  of  the  puerperal  state. 

Some,  degree  of  nervous  shock  or  exhaustion  is  observable  after 
most  labors.  In  many  cases  it  is  entirely  absent ;  in  others  it  is  well 
marked.  Its  amount  is  in  proportion  to  the  severity  of  the  labor 
and  the  susceptibility  of  the  patient ;  and  it  is,  therefore,  most  likely 
to  be  excessive  in  women  who  have  suffered  greatly  from  pain,  who 
have  undergone  much  muscular  exertion,  or  who  have  been  weakened 
from  undue  loss  of  blood.  It  is  evidenced  by  a  feeling  of  exhaustion 
and  fatigue,  and  not  uncommonly  there  is  some  shivering,  which  soon 
passes  off,  and  is  generally  followed  by  refreshing  sleep.  The  extreme 
nervous  susceptibility  continues  for  a  considerable  time  after  delivery, 
and  indicates  the  necessity  of  keeping  the  lying-in  patient  as  free  from 
all  sources  of  excitement  as  possible. 

Immediately  after  delivery  the  pulse  falls,  and  the  importance  of 
this  as  indicating  a  favorable  state  of  the  patient  has  already  been 
alluded  to.  The  condition  of  the  pulse  has  been  carefully  studied  by 
Blot,1  who  has  shown  that  this  diminution,  which  he  believes  to  be 
connected  with  a  diminished  tension  in  the  arteries  due  to  the  sudden 
arrest  of  the  uterine  circulation,  continues,  in  a  large  proportion  of 
cases,  for  a  considerable  number  of  days  after  delivery ;  and,  as  a 
matter  of  clinical  import,  as  long  as  it  does,  the  patient  may  be  con- 
sidered to  be  in  a  favorable  state.  In  many  instances  the  slowness  of 

1  Arch.  gen.  de  Med.,  1864. 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.      577 

the  pulse  is  remarkable,  often  sinking  to  fifty  or  even  forty  beats  per 
minute.  Any  increase  above  the  normal  rate,  especially  if  at  all  con- 
tinuous, should  always  be  carefully  noted  and  looked  on  with  suspi- 
cion. In  connection  with  this  subject,  however,  it  must  be  remembered 
that  in  puerperal  women  the  most  trivial  circumstances  may  cause 
a  sudden  rise,  of  the  pulse.  This  must  be  familar  to  every  practical 
obstetrician,  who  has  constant  opportunities  of  observing  this  effect 
after  any  transient  excitement  or  fatigue.  In  lying-in  hospitals  it  has 
generally  been  observed  that  the  occurrence  of  any  particularly  bad 
case  will  send  up  the  pulse  of  all  the  other  Datients  who  may  have 
heard  of  it. 

Temperature  in  the  Puerperal  State. — The  temperature  in  the 
lying-in  state  affords  much  valuable  information.  During  and  for  a 
short  time  after  labor  there  is  a  slight  elevation.  It  soon  falls  to,  or 
even  somewhat  below,  the  normal  level.  Squire  found  that  the  fall 
occurred  within  twenty-four  hours,  sometimes  within  twelve  hours 
after  the  termination  of  labor.1  For  a  few  days  there  is  often  a  slight 
increase  of  temperature,  especially  toward  the  evening,  which  is  prob- 
ably caused  by  the  rapid  oxidation  of  tissue  in  connection  with  the 
involution  of  the  uterus.  In  about  forty-eight  hours  there  is  a  rise 
connected  with  the  establishment  of  lactation,  amounting  to  one  or  two 
degrees  over  the  normal  level ;  but  this  again  subsides  as  soon  as  the 
milk  is  freely  secreted.  Crede  has  also  shown  2  that  rapid,  but  transient, 
rises  of  temperature,  may  occur  at  any  period,  connected  with  trivial 
causes,  such  as  constipation,  errors  of  diet,  or*  mental  disturbances. 
But  if  there  be  any  rise  of  temperature  which  is  at  all  continuous, 
especially  to  over  100°  Fahr.,  and  associated  with  rapidity  of  the 
pulse,  there  is  reason  to  fear  the  existence  of  some  complication. 

The  Secretions  and  Excretions. — The  various  secretions  and  ex- 
cretions are  carried  on  with  increased  activity  after  labor.  The  skin 
especially  acts  freely,  the  patient  often  sweating  profusely.  There  is 
also  an  abundant  secretion  of  urine,  but  not  uncommonly  a  difficulty 
of  voiding  it,  either  on  account  of  temporary  paralysis  of  the  neck  of 
the  bladder,  resulting  from  the  pressure  to  which  it  has  been  subjected, 
or  from  swelling  and  occlusion  of  the  urethra.  For  the  same  reason 
the  rectum  is  sluggish  for  a  time,  and  constipation  is  not  infrequent. 
The  appetite  is  generally  indifferent,  and  the  patient  is  often  thirsty. 

Generally  in  about  forty-eight  hours  the  secretion  of  milk  becomes 
established,  and  this  is  occasionally  accompanied  by  a  certain  amount 
of  constitutional  irritation.  The  breasts  often  become  turgid,  hot,  and 
painful.  There  may  or  may  not  be  some  general  disturbance,  quick- 
ening of  pulse,  elevation  of  temperature,  possibly  slight  shivering  and 
a  general  sense  of  oppression,  which  are  quickly  relieved  as  the  milk 
is  formed  and  the  breasts  emptied  by  suckling.  Squire  says  that  the 
most  constant  phenomenon  connected  with  the  temperature  is  a  slight 
elevation  as  the  milk  is  secreted,  rapidly  falling  when  lactation  is 
established.  Barker  noted  elevation,  either  of  temperature  or  pulse, 
in  only  four  out  of  fifty-two  cases  that  were  carefully  watched.  There 

1  "  Puerperal  Temperatures,"  Obstetrical  Transactions,  1868,  vol.  ix.  p.  129. 
»  Monats.  f.  Geburt.,  1868,  Bd.  xxxii.  S.  453. 

37 


578  THE    PUERPERAL    STATE. 

can  be  little  doubt  that  the  importance  of  the  so-called  "  milk  fever  " 
has  been  immensely  exaggerated,  and  its  existence,  as  a  normal  accom- 
paniment of  the  puerperal  state,  is  more  than  doubtful.  It  is  certain, 
however,  that  in  a  small  minority  of  cases  there  is  an  appreciable 
amount  of  disturbance  about  the  time  that  the  milk  is  formed.  Out 
of  423  cases,  Macau1  found  that  in  114,  or  about  27  per  cent.,  there 
was  no  rise  of  temperature ;  in  226  the  temperature  did  rise  to  100° 
and  over,  and  of  these  in  32,  or  a  little  over  7  cent.,  the  only  ascer- 
taiuable  cause  was  a  painful  or  distended  condition  of  the  breast. 
Many  modern  writers,  such  as  "NVinckel,  Griinewaldt,  and  D'Espiiie, 
entirely  deny  the  connection  of  this  disturbance  with  lactation,  and 
refer  it  to  a  slight  and  transient  septicaemia.  Graily  Hewitt  remarks 
that  it  is  most  commonly  met  with  when  the  patient  is  kept  low  and 
on  deficient  diet  after  delivery,  especially  Avhen  the  system  is  below 
par  from  hemorrhage  or  any  other  cause.  This  observation  will,  no 
doubt,  account  for  the  comparative  rarity  of  febrile  disturbance  in 
connection  with  lactation  in  these  days,  in  which  the  starving  of  puer- 
peral patients  is  not  considered  necessary.  It  is  certain  that  anything 
deserving  the  name  of  milk  fever  is  now  altogether  exceptional,  and 
such  feverishness  as  exists  is  generally  quite  transient.  It  is  also  a 
fact  that  it  is  most  apt  to  occur  in  delicate  and  weakly  women,  espe- 
cially in  those  who  do  not,  or  are  unable  to,  nurse.  There  does  not, 
however,  seem  to  be  any  sufficient  reason  for  referring  it,  even  when 
tolerably  well  marked,  to  septicaemia.  The  relief  which  attends  the 
emptying  of  the  breasts  seems  sufficient  to  prove  its  connection  with 
lactation,  and  the  discomfort  which  is  necessarily  associated  with  the 
swollen  and  turgid  mammae  is,  of  itself,  quite  sufficient  to  explain  it. 

In  the  urine  of  women  during  lactation  an  appreciable  amount  of 
sugar  may  readily  be  detected.  The  amount  varies  according  to  the 
condition  of  the  breasts.  It  increases  when  they  are  turgid  and  con- 
gested, and  is,  therefore,  most  abundant  in  women  in  whom  the 
breasts  are  not  emptied,  as  when  the  child  is  dead,  or  when  lactation  is 
not  attempted. 

Contraction  of  the  Uterus  after  Delivery. — Immediately  after 
delivery  the  uterus  contracts  firmly,  and  can  be  felt  at  the  lower  part 
of  the  abdomen  as  a  hard,  firm  mass,  about  the  size  of  a  cricket-ball. 
(Plate  V.)  After  a  time  it  again  relaxes  somewhat,  and  alternate 
relaxations  and  contractions  go  on  at  intervals  for  a  considerable  time 
after  the  expulsion  of  the  placenta.  The  more  complete  and  perma- 
nent the  contraction,  the  greater  the  safety  and  comfort  of  the  patient; 
for  when  the  organ  remains  in  a  state  of  partial  relaxation,  coagula 
are  apt  to  be  retained  in  its  cavity,  while,  for  the  same  reason,  air  enters 
more  readily  into  it.  Hence  decomposition  is  favored,  and  the  chances 
of  septic  absorption  are  much  increased ;  while  even  when  this  does 
not  occur,  the  muscular  fibres  are  excited  to  contract,  and  severe  after- 
pains  are  produced. 

After  the  first  few  days  the  diminution  in  the  size  of  the  uterus  pro- 
gresses with  great  rapidity.  By  about  the  sixth  day  it  is  so  much 

1  Dublin  Quarterly  Journ.  of  Med.  Science,  1878,  vol.  Ixv.  p.  435. 


UJ 

I- 


_;    03 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.      579 

lessened  as  to  project  not  more  than  one  and  a  half  or  two  inches  above 
the  pelvic  brim,  while  by  the  eleventh  day  it  is  no  longer  to  be  made 
out  by  abdominal  palpation.  Its  increased  size  is,  however,  still  ap- 
parent per  vayinam,  and  should  occasion  arise  for  making  internal 
examination,  the  mass  of  the  lower  segment  of  the  uterus,  with  its 
flabby  and  patulous  cervix,  can  be  felt  for  some  weeks  after  delivery. 
This  may  sometimes  be  of  practical  value  in  cases  in  which  it  is  neces- 
sary to  ascertain  the  fact  of  recent  delivery,  and  under  these  circum- 
stances, as  pointed  out  by  Simpson,  the  uterine  sound  would  also  enable 
us  to  prove  that  the  cavity  of  the  uterus  is  considerably  elongated. 
Indeed,  the  normal  condition  of  the  uterus  and  cervix  is  not  regained 
until  six  weeks  or  two  months  after  labor.  These  observations  are 
corroborated  by  investigations  on  the  weight  of  the  organ  at  diiferent 
periods  after  labor.  Thus  Heschl l  has  shown  that  the  uterus,  imme- 
diately after  delivery,  weighs  about  twenty-two  to  twenty-four  ounces ; 
within  a  week,  it  weighs  nineteen  to  twenty-one  ounces ;  and  at  the 
end  of  the  second  week,  ten  to  eleven  ounces  only.  At  the  end  of  the 
third  week,  it  weighs  five  to  seven  ounces ;  but  it  is  not  until  the  end 
of  the  second  month  that  it  reaches  its  normal  weight.  Hence  it 
appears  that  the  most  rapid  diminution  occurs  during  the  second  week 
after  delivery. 

Fatty  Transformation  of  the  Muscular  Fibres. — The  mode  in 
which  this  diminution  in  size  is  effected  is  by  the  transformation  of 
the  muscular  fibres  into  molecular  fat,  which  is  absorbed  into  the 
maternal  vascular  system,  which,  therefore,  becomes  loaded  with  a 
large  amount  of  effete  material.  Heschl  believed  that  the  entire  mass 
of  the  enlarged  uterine  muscles  is  removed,  and  replaced  by  newly- 
formed  fibres,  which  commence  to  be  developed  about  the  fourth  week 
after  delivery,  the  change  being  complete  about  the  end  of  the  second 
month.  Luschka  and  Robin2  contend  that  this  entire  change  in  the 
structure  of  the  fibres  does  not  occur,  but  that  their  diminution  in  size 
is  effected  by  granular  degeneration  and  subsequent  absorption  of  the 
existing  muscle  cells,  by  means  of  which  they  become  gradually 
reduced  to  their  natural  size.  This  view  has  been  more  recently  main- 
tained by  Sanger.  Generally  speaking,  involution  goes  on  without 
interruption.  It  is,  however,  apt  to  be  interfered  with  by  a  variety  of 
causes,  such  as  premature  exertion,  intercurrent  disease,  and  very  prob- 
ably by  neglect  of  lactation.  Hence  the  uterus  often  remains  large 
and  bulky,  and  the  foundation  for  many  subsequent  uterine  ailments 
is  laid. 

Changes  in  the  Uterine  Vessels. — Williams3  lias  drawn  attention 
to  changes  occurring  in  the  vessels  of  the  uterus,  some  of  wrhich  seem 
to  be  permanent,  and  may,  should  further  observations  corroborate  his 
investigations,  prove  of  value  in  enabling  us  to  ascertain  whether  a 
uterus  is  uulliparous  or  the  reverse;  a  question  which  may  be  of 
medico-legal  importance.  After  pregnancy  he  found  all  the  vessels 
enlarged  in  calibre.  The  coats  of  the  arteries  are  thickened  and 

1  Researches  on  the  Conduct  of  the  Human  Uterus  after  Delivery. 

8  "The  Involution  of  the  Muscular  Tissue  of  the  Puerperal  Uterus,"  Annals  of  Gynecology, 
Boston,  July,  isss. 
*  "  Changes  in  the  Uterus  resulting  from  Gestation,"  Obst.  Trans.,  vol.  xx. 


580 


THE    PUERPERAL    STATE. 


hypertrophied,  and  this  he  has  observed  even  in  the  uteri  of  aged 
women  who  have  not  borne  children  for  many  years.  The  venous 
sinuses,  especially  at  the  placenta!  site,  have  their  walls  greatly 
thickened  and  convoluted,  and  contain  in  their  centre  a  small  clot  of 
blood  (Fig.  206).  This  thickening  attains  its  greatest  dimensions  in 
the  third  month  after  gestation,  but  traces  of  it  may  be  detected  as  late 
as  ten  or  twelve  weeks  after  labor. 

Changes  in  the  Uterine  Mucous  Membrane. — The  changes  going 
on  in  the  lining  membrane  of  the  uterus  immediately  after  delivery  are 
of  great  importance  in  leading  to  a  knowledge  of  the  puerperal  state, 
and  have  already  been  discussed  when  describing  the  decidua  (p.  106). 


Section  of  a  uterine  sinus  from  the  placental  site  nine  weeks  after  delivery. 
(After  WILLIAMS.) 

Its  cavity  is  covered  with  a  reddish-gray  film,  formed  of  blood  and 
fibrin.  The  open  mouths  of  the  uterine  sinuses  are  still  visible,  more 
especially  over  the  site  of  the  placenta,  and  thrombi  may  be  seen  pro- 
jecting from  them.  The  placental  site  can  be  distinctly  made  out  in 
the  form  of  an  irregularly  oval  patch,  where  the  lining  membrane  is 
thicker  than  elsewhere.  (See  Plate  V.) 

Contraction  of  the  Vagina,  etc. — The  vagina  soon  contracts,  and 
by  the  time  the  puerperal  month  is  over  it  lias  returned  to  its  normal 
dimensions,  but  after  childbearing  it  always  remains  more  lax  and 
less  rugose  than  in  nulliparse.  The  vulva,  at  first  very  lax  and  much 
distended,  soon  regains  its  former  state.  The  abdominal  parietes  re- 
main loose  and  flabby  for  a  considerable  time,  and  the  white  streaks, 
produced  by  the  distention  of  the  cutis  very  generally  become  per- 
manent. In  some  women,  especially  when  proper  support  by  band- 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.      581 

aging  has  not  been  given,  the  abdomen  remains  permanently  loose  and 
pendulous. 

The  Lochial  Discharge. — From  the  time  of  delivery  up  to  about 
three  weeks  afterward  a  discharge  escapes  from  the  interior  of  the 
uterus,  known  as  the  lochia.  At  first  this  consists  almost  entirely  of 
pure  blood,  mixed  with  a  variable  amount  of  coagula.  If  efficient 
uterine  contraction  has  not  been  secured  after  the  expulsion  of  the 
placenta,  coagula  of  considerable  size  are  frequently  expelled  with  the 
lochia  for  one  or  two  days  after  delivery.  In  three  or  four  days  the 
distinctly  bloody  character  of  the  lochia  is  altered.  They  have  a  red- 
dish watery  appearance,  and  are  known  as  the  lochia  i^ubra  or  cruenta. 
According  to  the  researches  of  Wertheirner,1  they  are  at  this  time 
composed  chiefly  of  blood  corpuscles,  mixed  with  epithelium  scales, 
mucous  corpuscles,  and  the  debris  of  the  decidua.  The  change  in  the 
appearance  of  the  discharge  progresses  gradually,  and  about  the  seventh 
or  eighth  day  it  has  no  longer  a  red  color,  but  is  a  pale  greenish  fluid, 
with  a  peculiar  sickening  and  disagreeable  odor,  and  is  familiarly 
described  as  the  "  green  waters."  It  now  contains  a  small  quantity 
of  blood  corpuscles,  which  lessen  in  amount  from  day  to  day,  but  a 
considerable  number  of  pus  corpuscles,  which  remain  the  principal 
constituent  of  the  discharge  until  it  ceases.  Besides  these,  epithelial 
scales,  fatty  granules,  and  crystals  of  cholesterin  are  observed.  Vari- 
ous micro-organisms  are  found  in  the  discharge,  especially  in  the  lower 
part  of  the  vagina,  such  as  the  trichomonas  vaginalis,  streptococci,  rod 
bacteria,  and  others,  and  they  increase  in  numbers  toward  the  end  of 
the  week  after  delivery.  The  conditions  existing  in  the  vagina  greatly 
favor  their  growth,  and  hence  the  special  importance  of  strict  attention 
to  cleanliness  and  antiseptic  precautions  during  convalescence. 

The  amount  of  the  lochia  varies  much,  and  in  some  women  it 
is  habitually  more  abundant  than  in  others.  Under  ordinary  circum- 
stances it  is  very  scanty  after  the  first  fortnight,  but  occasionally  it 
continues  somewhat  abundant  for  a  month  or  more,  without  any  bad 
results.  It  is  apt  again  to  become  of  a  red  color,  and  to  increase  in  quan- 
tity, in  consequence  of  any  slight  excitement  or  disturbance.  If  this 
red  discharge  continues  for  any  undue  length  of  time,  there  is  reason 
to  suspect  some  abnormality,  and  it  may  not  imfrequently  be  traced  to 
slight  lacerations  about  the  cervix,  which  have  not  healed  properly. 
This  result  may  also  follow  premature  exertion,  interfering  with  the 
proper  involution  of  the  uterus;  and  the  patient  should  certainly  not  be 
allowed  to  move  about  as  long  as  much  colored  discharge  is  going  on. 

Occasionally  the  lochia  have  an  intensely  fetid  odor.  This  must 
always  give  rise  to  some  anxiety,  since  it  often  indicates  the  retention 
and  putrefaction  of  coagula,  and  involves  the  risk  of  septic  absorption. 
It  is  not  very  rare,  however,  to  observe  a  most  disagreeable  odor  per- 
sist in  the  lochia  without  any  bad  results.  The  fetor  always  deserves 
careful  attention,  and  an  endeavor  should  be  made  to  obviate  it  by 
directing  the  nurse  to  syringe  out  the  vagina  freely  night  and  morning 
with  creolin  and  water;  while,  if  it  be  associated  with  quickened 

i  Virchow's  Arch.,  1861 


582  THE    PUERPERAL    STATE. 

pulse  and  elevated  temperature,  other  measures,  to  be  subsequently 
described,  will  be  necessary. 

The  after-pains,  which  many  childbearing  women  dread  even  more 
than  the  labor  pains,  are  irregular  contractions  occurring  for  a  vary- 
ing time  after  delivery,  and  resulting  from  the  efforts  of  the  uterus  to 
expel  coagula  which  have  formed  in  its  interior.  If,  therefore,  special 
care  be  taken  to  secure  complete  and  permanent  contraction  after  labor, 
they  rarely  occur,  or  to  a  very  slight  extent.  Their  dependence  on 
uterine  inertia  is  evidenced  by  the  common  observation  that  they  are 
seldom  met  with  in  primiparse,  in  whom  uterine  contraction  may  be 
supposed  to  be  more  efficient,  and  are  more  frequent  in  women  who 
have  borne  many  children.  They  are  a  preventable  complication,  and 
one  which  need  not  give  rise  to  any  anxiety  ;  they  are,  indeed,  rather 
salutary  than  the  reverse ;  for,  if  coagula  be  retained  in  utero,  the 
sooner  they  are  expelled  the  better.  The  after-pains  generally  begin 
a  few  hours  after  delivery,  and  continue  in  bad  cases  for  three  or  four 
days,  but  seldom  longer.  They  are  generally  increased  when  the 
mammae  are  irritated  by  suction.  AVhen  at  their  height  they  are  often 
relieved  by  the  expulsion  of  the  coagula.  In  some  severe  cases  they 
are  apparently  neuralgic  in  character,  and  do  not  seem  to  depend  on 
the  retention  of  coagula.  They  may  be  readily  distinguished  from 
pains  due  to  more  serious  causes,  by  feeling  the  enlarged  uterus  harden 
under  their  influence,  by  the  uterus  not  being  tender  on  pressure,  and 
by  the  absence  of  any  constitutional  symptoms. 

The  management  of  women  after  childbirth  has  varied  much  at 
different  times,  according  to  fashion  or  theory.  The  dread  of  inflam- 
mation long  influenced  the  professional  mind  and  caused  the  adoption 
of  a  strictly  antiphlogistic  diet,  which  led  to  a  tardy  convalescence. 
The  recognition  of  the  essentially  physiological  character  of  labor  has 
resulted  in  more  sound  views,  with  manifest  advantage  to  our  patients. 
The  main  facts  to  bear  in  mind  with  regard  to  the  puerperal  woman 
are  :  her  nervous  susceptibility,  which  necessitates  quiet  and  absence  of 
all  excitement ;  the  importance  of  favoring  involution  by  prolonged 
rest;  and  the  risk  of  septicaemia,  which  calls  for  perfect  cleanliness 
and  attention  to  hygienic  precautions. 

As  soon  as  we  are  satisfied  that  the  uterus  is  perfectly  contracted 
and  that  all  risk  of  hemorrhage  is  over,  the  patient  should  be  left  to 
sleep.  Many  practitioners  administer  an  opiate ;  but  as  a  matter  of 
routine  this  is  certainly  not  good  practice,  since  it  checks  the  contrac- 
tions of  the  uterus  and  often  produces  unpleasant  effects.  Still,  if  the 
labor  have  been  long  and  tedious,  and  the  patient  be  much  exhausted, 
fifteen  or  twenty  drops  of  Battley's  solution  may  be  administered  with 
advantage. 

Within  a  few  hours  the  patient  should  be  seen,  and  at  the  first  visit 
particular  attention  should  be  paid  to  the  state  of  the  pulse,  the  uterus, 
and  the  bladder.  The  pulse  during  the  whole  period  of  convalescence 
should  be  carefully  watched,  and,  if  it  be  at  all  elevated,  the  tempera- 
ture should  at  once  be  taken.  If  the  pulse  and  temperature  remain 
normal,  we  may  be  satisfied  that  tilings  are  going  on  wrell ;  but  if  the 
one  be  quickened  and  the  other  elevated,  some  disturbance  or  compli- 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.      583 

cation  may  be  apprehended.  The  abdomen  should  be  felt,  to  see  that 
the  uterus  is  not  unduly  distended  and  that  there  is  no  tenderness. 
After  the  first  day  or  two  this  is  no  longer  necessary. 

Treatment  of  Retention  of  Urine. — Sometimes  the  patient  cannot 
at  first  void  the  urine;  and  the  application  of  a  hot  sponge  over  the 
pubes  may  enable  her  to  do  so.  If  the  retention  of  urine  be  due  to 
temporary  paralysis  of  the  bladder,  three  or  four  20-minim  doses  of 
the  liquid  extract  of  ergot,  at  intervals  of  half  an  hour,  may  prove 
successful.  Many  hours  should  not  be  allowed  to  elapse  without 
relieving  the  patient  by  the  catheter,  since  prolonged  retention  is  only 
likely  to  make  matters  worse.  In  many  cases  the  use  of  the  catheter 
may  be  avoided  by  propping  up  the  patient  in  the  sitting  posture,  in 
which  she  is  often  able  to  micturate  when  she  cannot  do  so  lying,  and 
this  plan  has  the  further  advantage  of  allowing  the  lochia  to  drain 
away  from  the  vagina.  It  may  be  necessary,  subsequently,  to  empty 
the  bladder  night  and  morning,  until  the  patient  regain  her  power 
over  it,  or  until  the  swelling  of  the  urethra  subsides,  and  this  will 
generally  be  the  case  in  a  few  days.  The  utmost  care  should  be  taken 
to  keep  the  catheter  aseptic,  and  it  should  lie  in  a  basin  of  1  :  1000 
sublimate  solution,  otherwise  its  frequent  use  might  lead  to  cystitis. 
Occasionally  the  bladder  becomes  largely  distended,  and  is  relieved  to 
some  degree  by  dribbling  of  urine  from  the  urethra.  Such  a  state  of 
things  may  deceive  the  patient  and  nurse,  and  may  produce  serious 
consequences.  Attention  to  the  condition  of  the  abdomen  will  prevent 
the  practitioner  from  being  deceived,  for  in  addition  to  some  constitu- 
tional disturbance,  a  large,  tender,  and  fluctuating  swelling  will  be  found 
in  the  hypogastric  region  distinct  from  the  uterus,  which  it  displaces 
to  one  or  other  side.  The  catheter  will  at  once  prove  that  this  is  pro- 
duced by  distention  of  the  bladder. 

Treatment  of  Severe  After-pains. — If  the  after-pains  be  very 
severe,  an  opiate  may  be  administered,  or,  if  the  lochia  be  not  over- 
abundant, a  linseed-meal  poultice,  sprinkled  with  laudanum,  or  with 
the  chloroform  and  belladonna  liniment,  may  be  applied.  If  proper 
care  have  been  taken  to  induce  uterine  contraction,  they  will  seldom 
be  sufficiently  severe  to  require  treatment.  In  America  quinine,  in 
doses  of  10  grains  twice  daily,  has  been  strongly  recommended,  espe- 
cially when  opiates  fail  and  when  the  pains  are  neuralgic  in  character, 
and  I  have  found  this  remedy  answer  extremely  well.  The  quinine  is 
best  given  in  solution  with  10  or  15  minims  of  hydrobromic  acid, 
which  materially  lessens  the  unpleasant  head  symptoms  often  accom- 
panying the  administration  of  such  large  doses.  The  inhalation  of  the 
nitrite  of  amyl  in  severe  cases  is  said  to  be  very  efficacious.1 

Diet  and  Regimen. — The  diet  of  the  puerperal  patient  claims 
careful  attention,  the  more  so  as  old  prejudices  in  this  respect  are  as 
yet  far  from  exploded,  and  it  is  by  no  means  rare  to  find  mothers  and 
nurses  who  still  cling  tenaciously  to  the  idea  that  it  is  essential  to 
prescribe  a  low  regimen  for  many  days  after  labor.  The  erroneous- 
ness  of  this  plan  is  now  so  thoroughly  recognized  that  it  is  hardly 

i  Mr.  F.  W.  Kendle  :  Lancet,  1887,  vol.  i.  p.  606. 


584  THE    PUERPERAL    STATE. 

necessary  to  argue  the  point.  There  is,  however,  a  tendency  in  some 
to  err  in  the  opposite  direction,  which  leads  them  to  insist  on  the 
patient's  consuming  solid  food  too  soon  after  delivery  and  before  she 
has  regained  her  appetite,  thereby  producing  nausea  and  intestinal 
derangement.  Our  best  guide  in  this  matter  is  the  feelings  of  the 
patient  herself.  If,  as  is  often  the  case,  she  be  disinclined  to  eat, 
there  is  no  reason  why  she  should  be  urged  to  do  so.  A  good  cup  of 
beef-tea,  some  bread  and  milk,  or  an  egg  beaten  up  with  milk,  may 
generally  be  given  with  advantage  shortly  after  delivery,  and  many 
patients  are  not  inclined  to  take  more  for  the  first  day  or  so.  If  the 
patient  be  hungry  there  is  no  reason  why  she  should  not  have  some 
more  solid,  but  easily  digested  food,  such  as  white  fish,  chicken,  or 
sweetbread  ;  and,  after  a  day  or  two,  she  may  resume  her  ordinary  diet, 
bearing  in  mind  that,  being  confined  to  bed,  she  cannot  with  advan- 
tage consume  the  same  amount  of  solid  food  as  when  she  is  up  and 
about.  Dr.  Oldham,  in  his  presidential  address  to  the  Obstetrical 
Society,1  made  some  apposite  remarks  on  this  point  which  are  worthy 
of  quotation  :  "A  puerperal  month  under  the  guidance  of  a  monthly 
nurse  is  easily  drawn  out,  and  it  is  well  if  a  love  of  the  comforts  of 
illness  and  the  persuasion  of  being  delicate,  which  are  the  infirmities 
of  many  women,  do  not  induce  a  feeble  life  which  long  survives  after 
the  occasion  of  it  is  forgotten.  I  know  no  reason  why,  if  a  woman  is 
confined  early  in  the  morning,  she  should  not  have  her  breakfast  of 
tea  and  toast  at  nine,  her  luncheon  from  some  digestible  meat  at  one, 
her  cup  of  tea  at  five,  her  dinner  with  chicken  at  seven,  and  her  tea 
again  at  nine,  or  the  equivalent,  according  to  the  variation  of  her 
habits  of  living.  Of  course  there  is  the  common-sense  selection  of 
articles  of  food,  guarding  against  excess,  and  avoiding  stimulants. 
But  gruel  and  slops  and  all  intermediate  feeding  are  to  be  avoided." 
No  one  who  has  seen  both  methods  adopted  can  fail  to  have  been 
struck  with  the  more  rapid  and  satisfactory  convalesence  which  takes 
place  when  the  patient's  strength  is  not  weakened  by  an  unnecessarily 
low  diet.  Stimulants,  as  a  rule,  are  not  required ;  but  if  the  patient  be 
weakly  and  exhausted,  or  if  she  be  accustomed  to  their  use,  there  can 
be  no  reasonable  objection  to  their  judicious  administration. 

Attention  to  Cleanliness. — Immediately  after  delivery  a  warm 
napkin  or  pad  of  aseptic  wool  is  applied  to  the  vulva,  and  after  the 
patient  has  rested  a  little,  the  nurse  removes  the  soiled  linen  from  the 
bed  and  washes  the  external  genitals.  It  is  impossible  to  pay  too 
much  attention  during  the  subsequent  progress  of  the  case  to  the  main- 
tenance of  perfect  cleanliness.  Perfectly  antiseptic  midwifery  is  no 
doubt  an  impossibility,  but  a  near  approach  to  it  may  be  made,  and 
the  greater  the  care  taken  the  more  certainly  will  the  safety  of  the 
patient  be  insured.2  It  wrill  be  a  wise  precaution  to  advise  the  nurse 

1  Obst.  Trans.,  1865,  vol.  v.  p.  14. 

2  I  have  for  the  past  year  or  two  distributed  the  following  rules  to  the  monthly  nurses  attending 
my  own  patients,  with  the  result,  I  believe,  of  a  marked  improvement  in  their  comfort  and  a 
more  generally  satisfactory  convalescence : 

ANTISEPTIC  RULES  FOR  MONTHLY  NURSES. 

1.  Two  bottles  are  supplied  to  each  patient.  One  contains  a  mixture  of  perchloride  of  mercury, 
of  the  strength  of  1  part  to  1000  of  water  (called  the  1 : 1000  solution),  the  other  carbolized 
vaseline  (1 : 8). 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.       585 

never  to  touch  the  genitals  for  the  first  few  clays,  unless  her  hands 
have  been  moistened  in  a  1  : 20  solution  of  carbolic  acid,  or  1  : 1000 
solution  of  perchloride  of  mercury,  or  lubricated  with  carbolized 
vaseline.  The  linen  should  be  frequently  changed,  and  all  dirty  linen 
and  discharges  immediately  removed  from  the  apartment.  The  vulva 
should  be  washed  daily  with  a  solution  of  perchloride  of  mercury  of 
the  strength  of  1  : 2000,  or  with  creolin  and  water,  and  the  patient 
will  derive  great  comfort  from  having  the  vagina  gently  syringed 
out  once  a  day  with  the  latter  solution.  Systematic  douching  of  the 
vagina  has  been  found  prejudicial  in  lying-in  hospitals,  but  in  private 
practice,  used  as  here  advised,  I  am  quite  satisfied  of  its  utility.  The 
remarkable  diminution  of  mortality  which  has  followed  such  anti- 
septic precautions  in  lying-in  hospitals  well  shows  the  importance  of 
these  measures.  The  room  should  be  kept  tolerably  cool,  and  fresh 
air  freely  admitted. 

Action  of  the  Bowels. — It  is  customary,  on  the  morning  of  the 
second  or  third  day,  to  secure  an  action  of  the  bowels ;  and  there  is  no 
better  way  of  doing  this  than  by  a  large  enema  of  soap  and  water.  If 
the  patient  object  to  this,  and  the  bowels  have  not  acted,  some  mild 
aperient  may  be  administered,  such  as  a  small  dose  of  castor  oil,  a  few 
grains  of  colocynth  and  henbane  pill,  or  the  popular  French  aperient, 
the  "  Tamar  Iiidien." 

Lactation. — The  management  of  suckling  and  of  the  breasts  forms 
an  important  part  of  the  duties  of  the  monthly  nurse,  which  the  prac- 
titioner should  himself  superintend.  This  will  be  more  conveniently 
discussed  under  the  head  of  lactation. 

Importance  of  Prolonged  Rest. — The  most  important  part  of  the 
management  of  the  puerperal  state  is  the  securing  to  the  patient  pro- 
longed rest  in  the  horizontal  position,  in  order  to  favor  proper  involu- 
tion of  the  uterus.  For  the  first  few  days  she  should  be  kept  as  quiet 
and  still  as  possible,  not  receiving  the  visits  of  any  but  her  nearest 
relatives,  thus  avoiding  all  chance  of  undue  excitement.  It  is  cus- 
tomary among  the  better  classes  for  the  patient  to  remain  in  bed  for 
eight  or  ten  days ;  but,  provided  she  be  doing  well,  there  can  be  no 
objection  to  her  lying  on  the  outside  of  the  bed,  or  slipping  on  to  a 
sola,  somewhat  sooner.  After  ten  days  or  a  fortnight  she  may  be 
permitted  to  sit  on  a  chair  for  a  little,  but  I  am  convinced  that  the 
longer  she  can  be  persuaded  to  retain  the  recumbent  position,  the 
more  complete  and  satisfactory  will  be  the  progress  of  involution;  and 
she  should  not  be  allowed  to  walk  about  until  the  third  week,  about 

2.  A  small  basin  con  tain  ing  Che  1  : 1000  solution  must  always  stand  by  the  bedside  of  the  patient, 
and  the  nurse  must  Moroni/Mi/  rinse  her  hands  in  it  every  time  she  touches  the  patient  in  the 
neighborlioo  1  of  the  genital  organs,  for  washing  or  any  other  purpose  whatsoever,  before  or  during 
labor,  and  for  a  week  after  delivery. 

3.  Pledgets  of  cotton-wool  should  be  used  for  washing  the  genitals  instead  of  sponges. 

4.  Vaginal  and  rectal  pipes,  catheters,  etc.,  must  be  dipped  in  the  1  : 1000  solution  before  being 
used.    The  surfaces  of  slippers,  bedpans,  etc.,  should  also  be  sponged  \yith  it. 

5.  Vaginal  pipes,  enema-tubes,  catheters,  etc.,  should  be  smeared  with  the  carbolized  vaseline 
before  use 

6.  Unless  express  directions  are  given  to  the  contrary,  the  vagina  should  be  syringed  once  daily 
after  delivery  with  warm  water  with  sufficient  creolin  dropped  into  it  to  give  it  a  milky  hue. 

7.  All  soiled  linen,  diapers,  etc.,  should  be  immediately  removed  from  the  bedroom. 

N.B.—  These  rules  are  for  the  purpose  of  protecting  the  patient  from  the  risk  arising  from  acci- 
dental contamination  of  the  hands,  etc.  It  is,  therefore,  hoped  that  they  will  be  faithfully  and 
minutely  adhered  to. 


586  THE    PUERPERAL    STATE. 

which  time  she  may  also  be  permitted  to  take  a  drive.  If  it  be  borne 
in  mind  that  it  takes  from  six  weeks  to  two  months  for  the  uterus  to 
regain  its  natural  size,  the  reason  for  prolonged  rest  will  be  obvious. 
The  judicious  practitioner,  however,  while  insisting  on  this  point,  will 
take  measures  at  the  same  time  not  to  allow  the  patient  to  lapse  into  the 
habits  of  an  invalid,  or  to  give  the  necessary  rest  the  semblance  of  disease. 
Subsequent  Treatment. — Toward  the  termination  of  the  puer- 
peral month  some  slight  tonic,  such  as  small  doses  of  quinine  with 
phosphoric  acid,  may  be  often  given  with  advantage,  especially  if  con- 
valescence be  tardy.  Nothing  is  so  beneficial  in  restoring  the  patient 
to  her  usual  health  as  change  of  air,  and  in  the  upper  classes  a  short 
visit  to  the  seaside  may  generally  be  recommended,  with  the  certainty 
of  much  benefit. 


CHAPTER   II. 

MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC. 

Commencement  of  Respiration. — Almost  immediately  after  its 
expulsion,  a  healthy  child  cries  aloud,  thereby  showing  that  respiration 
is  established,  and  this  may  be  taken  as  a  signal  of  its  safety.  The 
first  respiratory  movements  are  excited,  partially  by  reflex  action 
resulting  from  the  contact  of  the  cold  external  air  with  the  cutaneous 
nerves,  and  partly  by  the  direct  irritation  of  the  medulla  oblougata, 
in  consequence  of  the  circulation  through  it  of  blood  no  longer 
oxygenated  in  the  placenta. 

Apparent  Death  of  the  Newborn  Child. — Not  unfrequently  the 
child  is  born  in  an  apparently  lifeless  state.  This  is  especially  likely 
to  be  the  case  when  the  second  stage  of  labor  has  been  unduly  pro- 
longed, so  that  the  head  has  been  subjected  to  long-continued  pressure. 
The  utero-placental  circulation  is  also  apt  to  be  injuriously  interfered 
with  before  the  birth  of  the  child  when  a  tardy  labor  has  produced 
tonic  contraction  of  the  uterus,  and  consequent  closure  of  the  uterine 
sinuses ;  or,  more  rarely,  from  such  causes  as  the  injudicious  adminis- 
tration of  ergot,  premature  separation  of  the  placenta,  or  compression 
of  the  umbilical  cord.  In  any  of  these  cases  it  is  probable  that  the 
arrest  of  the  utero-placental  circulation  induces  attempts  at  inspira- 
tion, which  are  necessarily  fruitless,  since  air  cannot  reach  the  lungs, 
and  the  foetus  may  die  asphyxiated ;  the  existence  of  the  respiratory 
movement  being  proved  on  post-mortem  examination  by  the  presence 
in  the  lungs  of  liquor  amnii,  mucus,  and  meconium,  and  by  the 
extravasation  of  blood  from  the  rupture  of  their  engorged  vessels. 

In  most  cases,  when  the  child  is  born  in  a  state  of  apparent  asphyxia, 
its  face  is  swollen  and  of  a  dark  livid  color.  It  not  infrequently 


MANAGEMENT    OF    THE    INFANT,   LACTATION,   ETC.      587 

makes  one  or  two  feeble  and  gasping  efforts  at  respiration  without  any 
definite  cry;  on  auscultation  the  heart  may  be  heard  to  beat  weakly 
and  slowly.  Under  such  circumstances  there  is  a  fair  hope  of  its 
recovery.  In  other  cases  the  child,  instead  of  being  turgid  and  livid 
in  the  face,  is  pale,  with  flaccid  limbs,  and  no  appreciable  cardiac 
action ;  then  the  prognosis  is  much  more  unfavorable. 

Treatment  of  Apparent  Death. — No  time  should  be  lost  in 
endeavoring  to  excite  respiration,  and,  at  first,  this  must  be  done  by 
applying  suitable  stimulants  to  the  cutaneous  nerves,  in  the  hope  of 
exciting  reflex  action.  The  cord  should  be  at  once  tied,  and  the  child 
removed  from  the  mother ;  for  the  final  uterine  contractions  have  so 
completely  arrested  the  utero-placental  circulation  as  to  render  it  no 
longer  of  any  value.  If  the  face  be  very  livid,  a  few  drops  of  blood 
may  with  advantage  be  allowed  to  flow  from  the  cord  before  it  is  tied, 
with  the  view  of  relieving  the  embarrassed  circulation.  Very  often 
some  slight  stimulus,  such  as  one  or  two  sharp  slaps  on  the  thorax,  or 
rapidly  rubbing  the  body  with  brandy  poured  into  the  palms  of  the 
hands,  will  suffice  to  induce  respiration.  Failing  this,  nothing  acts  so 
well  as  the  sudden  and  instantaneous  application  of  heat  and  cold. 
For  this  purpose  extremely  hot  water  is  placed  in  one  basin,  and 
quite  cold  water  in  another.  Taking  the  child  by  the  shoulders  and 
legs,  it  should  be  dipped  for  a  single  moment  into  the  hot  water,  and 
then  into  the  cold ;  and  these  alternate  applications  may  be  repeated 
once  or  twice,  as  occasion  requires.  The  effect  of  this  measure  is  often 
very  marked,  and  I  have  frequently  seen  it  succeed  when  prolonged 
efforts  at  artificial  respiration  have  been  made  in  vain. 

If  these  means  fail,  an  endeavor  must  be  at  once  made  to  carry  on 
respiration  artificially.  The  best  means  of  doing  this  have  been  ex- 
haustively studied  by  Dr.  Champneys,1  who  considers  the  only  two 
reliable  means  of  carrying  on  artificial  respiration  are  those  of  Schultze 
and  Sylvester.  The  Sylvester  method  is,  on  the  whole,  that  which  is 
most  easily  applied,  and,  on  account  of  the  compressibility  of  the 
thorax,  it  is  peculiarly  suitable  for  infants.  The  child  being  laid  on 
its  back,  with  the  shoulders  slightly  elevated  and  the  feet  held  in  an 
elongated  position  by  an  assistant,  the  elbows  are  grasped  by  the 
operator,  and  alternately  raised  above  the  head,  and  slowly  depressed 
against  the  sides  of  the  thorax,  being  at  the  same  time  everted,  so  as 
t<>  produce  the  effect  of  inspiration  and  expiration.  In  Schultze's 
method  the  child  is  grasped  on  either  side  of  the  thorax,  the  operator's 
thumbs  being  anterior,  the  index  fingers  being  in  the  axillae,  and  the 
remaining  fingers  on  the  child's  back.  The  operator's  arms  are  now 
stretched  out  so  that  the  child  hangs  at  arm's  length  between  his  knees. 
By  this  means  the  chest  is  expanded,  and  inspiratory  movements  are 
produced.  The  operator's  arms  are  now  swung  upward  until  they 
are  horizontal.  This  causes  the  child's  body  to  be  flexed,  its  head  is 
directed  downward,  and  its  legs  fall  toward  the  operator  until  the 
weight  of  its  body  rests  on  his  thimibs.  By  this  means  its  thorax  and 
abdomen  are  compressed,  its  diaphragm  is  forced  upward,  and  expira- 

1  Medico-Chir.  Trans.,  vol.  Ixiv.  pp.  41,  87,  and  vol.  Ixv.  p.  75. 


588  THE    PUERPERAL    STATE. 

tion  results.  If  now  the  child  be  again  swung  into  its  former  position, 
inspiration  follows. 

Other  means  of  exciting  respiration  have  been  recommended.  One 
of  them,  much  used  abroad,  is  the  artificial  insufflation  of  the  lungs 
by  means  of  a  flexible  catheter  guided  into  the  glottis,  or  by  placing 
a  handkerchief  over  the  child's  mouth  and  directly  insufflating  the 
lungs.  It  is  not  difficult  to  pass  the  end  of  a  catheter  into  the  glottis, 
using  the  little  finger  as  a  guide ;  and  once  in  position,  it  may  be  used 
to  blow  air  gently  into  the  lungs,  which  is  expelled  by  compression  on 
the  thorax,  the  insufflation  being  repeated  at  short  intervals  of  about 
ten  seconds.  One  advantage  of  this  plan  is  that  it  allows  the  liquor 
amnii  and  other  fluids,  which  may  have  been  drawn  into  the  lungs  in 
the  premature  efforts  at  respiration  before  birth,  to  be  sucked  up  into 
the  catheter,  and  so  removed  from  the  lungs.  Dr.  Champueys  recom- 
mends that  when  the  catheter  is  passed  into  the  trachea  for  about  three 
inches  from  the  child's  mouth,  the  thorax  should  be  gently  compressed, 
and  then  air  should  be  blown  through  the  catheter.  The  effect  of  this 
manoeuvre  is  that  any  mucus  or  fluids  in  the  trachea  pass  upward 
through  the  glottis  into  the  pharynx.  The  same  effect  may  be  pro- 
duced, but  less  perfectly,  by  placing  the  hand  over  the  nostrils  of  the 
child,  blowing  into  its  mouth,  and  immediately  afterward  compressing 
the  thorax.  One  of  these  methods  should  certainly  be  tried  if  all 
other  means  have  failed.  Faradization  along  the  course  of  the  phrenic 
nerve  is  a  promising  means  of  inducing  respiration,  which  should  be 
used  if  the  proper  apparatus  can  be  procured.  Encouragement  to 
persevere  in  our  endeavors  to  resuscitate  the  child  may  be  derived 
from  the  numerous  authenticated  instances  of  success  after  the  lapse 
of  a  considerable  time,  even  of  an  hour  or  more.  As  long  as  the 
cardiac  pulsations  continue,  however  feebly,  there  is  no  reason  to 
despair,  and  Champneys  has  collected  some  apparently  authenticated 
cases  in  which  children  seemingly  dead  have  been  buried  for  some 
hours  and  then  dug  up  and  restored  to  life. 

"Washing  and  Dressing  of  the  Child. — When  the  child  cries 
lustily  from  the  first,  it  is  customary  for  the  nurse  to  wash  and  dress 
it  as  soon  as  her  immediate  attendance  on  the  mother  is  no  longer 
required.  For  this  purpose  it  is  placed  in  a  bath  of  warm  water,  and 
carefully  soaped  and  sponged  from  head  to  foot.  With  the  view  of 
facilitating  the  removal  of  the  unctuous  material  with  which  it  is 
covered,  it  is  usual  to  anoint  it  with  cold  cream  or  olive  oil,  which  is 
washed  off  in  the  bath.  Xurses  are  apt  to  use  undue  roughness  in 
endeavoring  to  remove  every  particle  of  the  vernix  cascosa,  small 
portions  of  which  are  often  firmly  adherent.  This  mistake  should  be 
avoided,  as  these  particles  will  soon  dry  up  and  become  spontaneously 
detached.  The  cord  is  generally  wrapped  in  a  small  piece  of  charred 
linen,  which  is  supposed  to  have  some  slight  antiseptic  property,  and 
this  is  renewed  from  day  to  day  until  the  cord  has  withered  and  sepa- 
rated. This  generally  occurs  withiYi  a  week  ;  and  a  small  pad  of  soft 
linen  is  then  placed  over  the  umbilicus,  and  supported  by  a  flannel 
belly-band  placed  around  the  abdomen,  which  should  not  be  too  tight, 


MANAGEMENT    OF    THE    INFANT,   LACTATION,    ETC.      589 

for  fear  of  embarrassing  the  respiration.  By  this  means  the  tendency 
to  umbilical  hernia  is  prevented. 

The  clothing  of  the  infant  varies  according  to  fashion  and  the 
circumstances  of  the  parents.  The  important  points  to  bear  in  mind 
are  that  it  should  be  warm  (since  newly-born  children  are  extremely 
susceptible  to  cold),  and  at  the  same  time  light  and  sufficiently  loose 
to  allow  free  play  to  the  limbs  and  thorax.  All  tight  bandaging  and 
.swaddling,  such  as  is  so  common  in  some  parts  of  the  Continent, 
should  be  avoided,  and  the  clothes  should  be  fastened  by  strings  or  by 
sewing,  no  pins  being  used.  At  the  present  day  it  is  customary  not  to 
use  caps,  so  that  the  head  may  be  kept  cool.  The  utmost  possible 
attention  should  be  paid  to  cleanliness,  and  the  child  should  be  regu- 
larly bathed  in  tepid  water,  at  first  once  daily,  and  after  the  first  few 
weeks,  both  night  and  morning.  After  drying,  the  flexures  of  the 
thighs  and  arms,  and  the  nates,  should  be  dusted  with  violet  powder 
or  fuller's  earth,  to  prevent  chafing  of  the  skin.  The  excrements 
should  be  received  in  napkins  wrapped  around  the  hips,  and  great 
care  is  required  to  change  the  napkins  as  often  as  they  are  wet  or 
soiled,  otherwise  troublesome  irritation  will  arise.  A  neglect  of  this 
precaution,  and  the  washing  of  the  napkins  with  coarse  soap  or  soda, 
are  among  the  principal  causes  of  the  eruptions  and  excoriations  so 
common  in  badly-cared-for  children.  When  washed  and  dressed  the 
child  may  be  placed  in  its  cradle,  and  covered  with  soft  blankets  or  an 
eider-down  quilt. 

As  soon  as  the  mother  has  rested  a  little,  it  is  advisable  to  place  the 
child  to  the  breast.  This  is  useful  to  the  mother  by  favoring  uterine 
contraction.  Even  now  there  is  in  the  breasts  a  variable  quantity  of 
the  peculiar  fluid  known  a£  colostrum.  This  is  a  viscid  yellowish 
secretion,  different  in  appearance  from  the  thin  bluish  milk  which  is 
subsequently  formed.  Examined  under  the  microscope  it  is  found  to 
contain  some  milk-globules  and  a  number  of  large  granular  and 
small  fat  corpuscles.  It  has  a  purgative  property,  and  soon  produces, 
with  less  irritation  than  any  of  the  laxatives  so  generally  used,  a  dis- 
charge of  the  meconium  with  which  the  bowels  are  loaded.  Hence 
the  accoucheur  should  prohibit  the  common  practice  of  administering 
castor  oil,  or  other  aperient,  within  the  first  few  days  after  birth, 
although  there  can  be  no  objection  to  it  in  special  cases,  if  the  bowels 
appear  to  act  inefficiently  and  with  difficulty. 

Over-frequent  Suckling  should  be  Avoided. — For  the  first  few 
days,  and  until  the  secretion  of  milk  is  thoroughly  established,  the 
child  should  be  put  to  the  breast  at  long  intervals  only.  Constant 
attempts  at  suckling  an  empty  breast  lead  to  nothing  but  disappoint- 
ment, both  to  the  mother  and  child,  and,  by  unduly  irritating  the 
mammae,  sometimes  do  positive  harm.  Therefore,  for  the  first  day  or 
two,  it  is  sufficient  if  the  child  be  applied  to  the  breast  twice,  or  at 
most  three  times,  in  the  twenty-four  hours.  Nor  is  it  necessary  to  be 
apprehensive,  as  many  mothers  naturally  are,  that  the  child  will  suffer 
from  want  of  food.  A  few  spoonfuls  of  milk  and  water  being  given 
from  time  to  time,  the  child  may  generally  wait  without  injury  until 
the  milk  is  secreted.  This  is  generally  about  the  third  day,  when  the 


590  THE    PUERPERAL    STATE. 

secretion  is  found  to  be  a  whitish  fluid,  more  watery  in  appearance 
than  cow's  milk,  and  showing  under  the  microscope  an  abundance  of 
minute  spherical  globules,  refracting  light  strongly,  which  are  abun- 
dant in  proportion  to  the  quality  of  the  milk.  A  certain  number  of 
granular  corpuscles  may  also  be  observed  shortly  after  the  birth  of  the 
child,  but  after  the  first  month  these  should  have  almost  or  altogether 
disappeared.  The  reaction  of  human  milk  is  decidedly  alkaline,  and 
the  taste  much  sweeter  than  that  of  cow's  milk. 

The  importance  to  the  mother  of  nursing  her  own  child,  whenever 
her  health  permits,  on  account  of  the  favorable  influence  of  lactation 
in  promoting  a  proper  involution  of  the  uterus,  has  already  been  in- 
sisted on.  Unless  there  be  some  positive  contra-indication,  such  as  a 
marked  struinous  cachexia,  an  hereditary  phthisical  tendency,  or  great 
general  debility,  it  is  the  duty  of  the  accoucheur  to  urge  the  mother  to 
attempt  lactation,  even  if  it  be  not  carried  on  more  than  a  month  or 
two.  It  is,  however,  the  fact  that  in  the  upper  classes  of  society  a 
large  number  of  patients  are  unable  to  nurse,  even  though  willing 
and  anxious  to  do  so.  In  some  there  is  hardly  any  lacteal  secretion 
at  all,  in  others  there  is  at  first  an  over-abundance  of  watery  and  in- 
nutritious  milk,  Avhich  floods  the  breasts  and  soon  dies  away  alto- 
gether. Something  analogous  to  this  result  of  breeding  and  culture  is 
observed  in  the  lower  animals.  Thus  in  the  so-called  "pedigree" 
cattle,  the  cow  is  never  able  to  nurse  its  calf;  and  the  same  is  observed, 
though  less  constantly,  in  thoroughbred  racing  stock. 

When  the  Mother  cannot  Nurse,  a  Wet-nurse  should  be  Pro- 
cured.— Whenever  the  mother  cannot  or  will  not  nurse,  the  question 
will  arise  as  to  the  method  of  bringing  up  the  child.  From  many 
causes  there  is  an  increasing  tendency  t%  resort  to  bottle-feeding,  in- 
stead of  procuring  the  services  of  a  wet-nurse,  even  Avhen  the  question 
of  expense  does  not  come  into  consideration.  Xo  long  experience  is 
required  to  prove  that  hand-feeding  is  a  bad  and  imperfect  substitute 
for  Nature's  mode,  and  one  which  the  practitioner  should  discourage 
whenever  it  lies  in  his  power  to  do  so.  It  is  true  that,  in  many  cases, 
bottle-fed  children  do  well ;  but  there  is  good  reason  to  believe  that, 
even  when  apparently  most  successful,  the  children  are  not  so  strong 
in  after  life  as  they  would  have  been  had  they  been  brought  up  at  the 
breast.  When,  in  addition,  it  is  borne  in  mind  how  much  of  the 
success  of  hand-feeding  depends  on  intelligent  care  on  the  part  of  the 
nurse,  what  evils  are  apt  to  accrue  from  the  injurious  selection  of  food, 
and  from  ignorance  of  the  commonest  laws  of  dietetics,  there  is 
abundant  reason  for  urging  the  substitution  of  a  wet-nurse  whenever 
the  mother  is  unable  to  undertake  the  suckling  of  her  child.  It  must 
be  admitted  that  good  hand-feeding  is  better  than  bad  wet-nursing, 
and  the  success  of  the  latter  hinges  on  the  proper  selection  of  a  wet- 
nurse.  As  this  falls  within  the  duties  of  the  practitioner,  it  will  be 
well  to  point  out  the  qualities  which  should  be  sought  for  in  a  wet- 
nurse,  before  proceeding  to  discuss  the  mode  of  rearing  the  child  at 
the  breast. 

Selection  of  a  Wet-nurse. — In  selecting  a  wet-nurse  we  should 
endeavor  to  choose  a  strong,  healthy  woman,  who  should  not  be  over 


MANAGEMENT    OF    THE    INFANT,   LACTATION,   ETC.      591 

thirty  or  thirty-five  years  of  age  at  the  outside,  since  the  quality  of 
the  milk  deteriorates  in  women  who  are  more  advanced  in  life.  For 
a  similar  reason  a  very  young  woman  of  sixteen  or  seventeen  should 
be  rejected.  It  is  needless  to  say  that  care  must  be  taken  to  ascertain 
the  absence  of  all  traces  of  constitutional  disease,  especially  marks  of 
scrofula,  or  enlarged  cervical  or  inguinal  glands,  which  may  possibly 
be  due  to  antecedent  syphilitic  taint.  If  the  nurse  be  of  good  mus- 
cular development,  healthy-looking,  with  a  clear  complexion,  and 
sound  teeth  (indicating  a  generally  good  state  of  health),  the  color  of 
the  hair  and  eyes  is  of  secondary  importance.  It  is  commonly  stated 
that  brunettes  make  better  nurses  than  blondes,  but  this  is  by  no 
means  necessarily  the  case;  and  provided  all  the  other  points  be  favor- 
able, fairness  of  skin  and  hair  need  be  no  bar  to  the  selection  of  a 
nurse.  The  breasts  should  be  pear-shaped,  rather  firm,  as  indicating 
an  abundance  of  gland-tissue,  and  with  the  superficial  veins  well 
marked.  Large,  flabby  breasts  owe  much  of  their  size  to  an  undue 
deposit  of  fat,  and  are  generally  unfavorable.  The  nipple  should  be 
prominent,  not  too  large,  and  free  from  cracks  and  erosions,  which,  if 
existing,  might  lead  to  subsequent  difficulties  in  nursing.  On  press- 
ing the  breast  the  milk  should  flow  from  it  easily  in  a  number  of 
small  jets,  and  some  of  it  should  be  preserved  for  examination.  It 
should  be  of  a  bluish-white  color,  and  when  placed  under  the  micro- 
scope the  field  should  be  covered  with  an  abundance  of  milk  corpus- 
cles, and  the  large  granular  corpuscles  of  the  colostrum  should  have 
entirely  disappeared.  If  the  latter  be  observed  in  any  quantity  in  a 
woman  who  has  been  confined  five  or  six  weeks,  the  inference  is  that  the 
milk  is  inferior  in  quality.  It  is  not  often  that  the  practitioner  has  an 
opportunity  of  inquiring  into  the  moral  qualities  of  the  nurse,  although 
much  valuable  information  might  be  derived  from  a  knowledge  of  her 
previous  character.  An  irascible,  excitable,  or  highly  nervous  woman 
will  certainly  make  a  bad  nurse,  and  the  most  trivial  causes  might 
afterward  interfere  with  the  quality  of  her  milk.  Particular  attention 
should  be  paid  to  the  nurse's  own  child,  since  its  condition  affords  the 
best  criterion  of  the  quality  of  her  milk.  It  should  be  plump,  well- 
nourished,  and  free  from  all  blemishes.  If  it  be  at  all  thin  and 
wizened,  especially  if  there  be  any  snuffling  at  the  nose,  or  should  any 
eruption  exist  affording  the  slightest  suspicion  of  a  syphilitic  taint,  the 
nurse  should  be  unhesitatingly  rejected. 

Management  of  Suckling. — The  management  of  suckling  is  much 
the  same  whether  the  child  is  nursed  by  the  mother  or  by  a  wet- 
nurse.  As  soon  as  the  supply  of  milk  is  sufficiently  established,  the 
child  must  be  put  to  the  breast  at  short  intervals,  at  first  of  about  two 
hours,  and,  in  about  a  month  or  six  weeks,  of  three  hours.  From 
the  first  few  days  it  is  a  matter  of  the  greatest  importance,  both  to  the 
mother  and  child,  to  acquire  regular  habits  in  this  respect.  If  the 
mother  gets  into  the  way  of  allowing  the  infant  to  take  the  breast 
whenever  it  cries,  as  a  means  of  keeping  it  quiet,  her  own  health  must 
soon  suffer,  to  say  nothing  of  the  discomfort  of  being  incessantly  tied 
to  the  child's  side;  while  the  child  itself  has  not  sufficient  rest  to 
digest  its  food,  and  very  shortly  diarrhoea  or  other  symptoms  of 


592  THE    PUERPERAL    STATE. 

dyspepsia  are  pretty  sure  to  follow.  After  a  month  or  two  the  infant 
should  be  trained  to  require  the  breast  less  often  at  night,  so  as  to 
enable  the  mother  to  have  an  undisturbed  sleep  of  six  or  seven  hours. 
For  this  purpose  she  should  arrange  the  times  of  nursing  so  as  to  give 
the  breast  just  before  she  goes  to  bed,  and  not  again  until  the  early 
morning.  If  the  child  should  require  food  in  the  interval,  a  little 
milk  in  water,  from  the  bottle,  may  be  advantageously  given. 

Diet  of  Nursing  "Women. — The  diet  of  the  nursing  woman  should 
be  arranged  on  ordinary  principles  of  hygiene.  It  should  be  abundant, 
simple,  and  nutritious,  but  all  rich  and  stimulating  articles  of  food 
should  be  avoided.  A  common  error  in  the  diet  of  wet-nurses  is  over- 
feeding, which  constantly  leads  to  deterioration  of  the  milk.  Many 
of  these  women,  before  entering  on  their  functions,  have  been  living 
on  the  simplest  and  even  sparest  diet,  and  not  uncommonly,  in  the 
better  class  of  houses,  they  are  suddenly  given  heavy  meat  meals  three 
and  even  four  times  a  day,  and  often  three  or  four  glasses  of  stout.  It 
is  hardly  a  matter  of  astonishment  that,  under  such  circumstances, 
their  milk  should  be  found  to  disagree.  For  a  nursing  woman  in  good 
health  two  good  meat  meals  a  day,  with  two  glasses  of  beer  or  porter, 
and  as  much  milk  and  bread-and-butter  as  she  likes  to  take  in  the 
intervals,  should  be  amply  sufficient.  Plenty  of  moderate  exercise 
should  be  taken,  and  the  more  the  nurse  and  child  are  out  in  the  open 
air,  provided  the  weather  be  reasonably  fine,  the  better  it  is  for  both. 

[Usually  the  wet-nurses  employed  in  our  cities  are  of  foreign  birth; 
where  they  are  natives,  their  children  are  commonly  illegitimate.  An 
American  nurse  is  in  general  preferable,  and  as  a  rule  those  making 
application  have  not  been  in  the  habit  of  using  malt  drinks.  A  healthy 
woman  will  usually  nurse  well  on  her  ordinary  diet,  Avhich  should  be 
largely  farinaceous.  Ale  is  often  recommended  to  nursing  mothers, 
and  so  also  is  tea,  but  both  are  very  inferior  to  milk  and  farinaceous 
diets  prepared  with  milk.  Broma  prepared  with  cream  I  have  seen 
taken  once  a  day,  for  a  change,  with  advantage. — ED.] 

Signs  of  Successful  Lactation. — Carried  on  methodically  in  this 
manner,  -\vet-nursing  should  give  but  little  trouble.  In  the  intervals 
between  its  meals  the  child  sleeps  most  of  its  time,  and  wakes  with 
regularity  to  feed  ;  but  if  the  child  be  wakeful  and  restless,  cry  after 
feeding,  have  disordered  bowels,  and,  above  all,  if  it  do  not  gain,  week 
by  week,  in  weight  (a  point  which  should  be,  from  time  to  time,  ascer- 
tained by  the  scales),  we  may  conclude  that  there  is  either  some  grave 
defect  in  the  management  of  suckling,  or  that  the  milk  is  not  agreeing. 
Should  this  unsatisfactory  progress  continue,  in  spite  of  our  endeavor.-? 
to  remedy  it,  there  is  no  resource  left  but  the  alteration  of  the  diet, 
either  by  changing  the  nurse  or  by  bringing  up  the  child  by  hand. 
The  former  should.be  preferred  whenever  it  is  practicable,  and  in  the 
upper  ranks  of  life  it  is  by  no  means  rare  to  have  to  change  the  wet- 
nurse  two  or  three  times  before  one  is  met  with  whose  milk  agrees 
perfectly.  If  the  child  have  reached  six  or  seven  months  of  age,  it 
may  be  preferable  to  wean  it  altogether,  especially  if  the  mother  has 
nursed  it,  as  hand-feeding  is  much  less  objectionable  if  the  infant  has 
had  the  breast  for  even  a  few  mouths. 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.       593 

Period  of  "Weaning. — As  a  rule,  weaning  should  not  be  attempted 
until  dentition  is  fairly  established,  that  being  the  sign  that  Nature  has 
prepared  the  child  for  an  alteration  of  food ;  and  it  is  better  that  the 
main  portion  of  the  diet  should  be  breast  milk  until  at  least  six  or 
seven  teeth  have  appeared.  This  is  a  safer  guide  than  any  arbitrary 
rule  taken  from  the  age  of  the  child,  since  the  commencement  of  den- 
tition varies  much  in  different  cases.  About  the  sixth  or  seventh 
month  it  is  a  good  plan  to  commence  the  use  of  some  suitable  artificial 
food  once  a  day,  so  as  to  relieve  the  strain  on  the  mother  or  nurse,  and 
prepare  the  child  for  Aveauing,  which  should  always  be  a  very  gradual 
process.  In  this  way  a  meal  of  rusks  of  entire  wheat-flour,  or  of  beef- 
or  chicken-tea,  with  bread-crumb  in  it,  may  be  given  with  advantage; 
and  as  the  period  for  weaning  arrives  a  second  meal  may  be  added, 
and  so  eventually  the  child  may  be  weaned  without  distress  to  itself  or 
trouble  to  the  nurse. 

The  disorders  of  lactation  are  numerous,  and  as  they  frequently 
come  under  the  notice  of  the  practitioner,  it  is  necessary  to  allude  to 
some  of  the  most  common  and  important. 

Means  of  Arresting  the  Secretion  of  Milk. — The  advice  of  the 
accoucheur  is  often  required  in  cases  in  which  it  has  been  determined 
that  the  patient  is  not  to  nurse,  when  we  desire  to  get  rid  of  the  milk 
as  soon  as  possible,  or  when,  at  the  time  of  weaning,  the  same  object  is 
sought.  The  extreme  heat  and  distention  of  the  breasts,  in  the  former 
class  of  cases,  often  give  rise  to  much  distress.  A  smart  saline  aperient 
will  aid  in  removing  the  milk,  and  for  this  purpose  a  double  Seidlitz 
powder,  or  frequent  small  doses  of  sulphate  of  magnesia,  act  well ; 
while,  at  the  same  time,  the  patient  should  be  advised  to  take  as  small 
a  quantity  of  fluid  as  possible.  Iodide  of  potassium  in  large  doses  of 
twenty  or  twenty-five  grains,  repeated  twice  or  thrice,  has  a  remarkable 
effect  in  arresting  the  secretion  of  milk.  This  observation  was  first 
empirically  made  by  observing  that  the  secretion  of  milk  was  arrested 
when  this  drug  was  administered  for  some  other  cause ;  and  I  have 
frequently  found  it  answer  remarkably  well.  The  distention  of  the 
breasts  is  best  relieved  by  covering  them  with  a  layer  of  lint  or  cotton- 
wool, soaked  in  a  spirit  lotion  or  eau  de  Cologne  and  water,  over  which 
oiled  silk  is  placed,  and  by  directing  the  nurse  to  rub  them  gently  with 
warm  oil,  whenever  they  get  hard  and  lumpy.  Breast-pumps  and 
similar  contrivances  only  irritate  the  breasts,  and  do  more  harm  than 
good.  The  local  application  of  belladonna  has  been  strongly  recom- 
mended as  a  means  for  preventing  lacteal  secretion.  As  usually 
applied,  in  the  form  of  belladonna  plaster,  it  is  likely  to  prove  hurtful, 
since  the  breast  often  enlarges  after  the  plasters  are  applied,  and  the 
pressure  of  the  unyielding  leather  on  which  they  are  spread  produces 
intense  suffering.  A  better  way  of  using  it  is  by  rubbing  down  a 
drachm  of  the  extract  of  belladonna  with  an  ounce  of  glycerin,  and 
applying  this  on  lint.  In  some  cases  it  answers  extremely  well ;  but 
it  is  very  uncertain  in  its  action,  and  frequently  is  quite  useless. 

Defective  Secretion  of  Milk. — A.  deficiency  of  milk  in  nursing- 
mothers  is  a  very  common  source  of  difficulty.  In  a  wet-nurse  this 
drawback  is,  of  course,  an  indication  for  changing  the  nurse  :  but  to 

38 


594  THE    PUERPERAL    STATE. 

the  mother  the  importance  of  nursing  is  so  great  that  an  endeavor 
must  be  made  either  to  increase  the  flow  of  milk  or  to  supplement  it 
by  other  food.  Unfortunately,  little  reliance  can  be  placed  on  any  of 
the  so-called  galactagogues.  The  only  one  which  in  recent  times  has 
attracted  attention  is  the  leaves  of  the  castor-oil  plant,  which,  made 
into  poultices  and  applied  to  the  breast,  are  said  to  have  a  beneficial 
effect  in  increasing  the  flow  of  milk.  More  reliance  may  be  placed  in 
a  sufficiency  of  nutritious  food,  especially  such  as  contains  phosphatic 
elements ;  stewed  eels,  oysters,  and  other  kinds  of  shell-fish,  and  the 
Revalenta  Arabica,  are  recommended  by  Dr.  Routh,  who  has  paid  some 
attention  to  this  point,1  as  peculiarly  appropriate.  If  the  amount  of 
milk  be  decidedly  deficient,  the  child  should  be  less  often  applied  to 
the  breast,  so  as  to  allow  milk  to  collect,  and  properly  prepared  cow's 
milk  from  a  bottle  should  be  given  alternately  with  the  breast.  This 
mixed  diet  generally  answers  well,  and  is  far  preferable  to  pure  hand- 
feeding. 

[There  is  no  diet  equivalent  to  milk  for  a  nursing-mother,  where  it 
agrees  with  her.  This  I  have  tested  repeatedly  in  women  who  had 
failed  entirely  in  former  attempts  to  nurse  their  infants.  One  lady  who 
had  lost  her  milk  three  times  at  the  end  of  a  month,  and  had  nursed 
two  babies  into  starvation,  was  enabled  to  nurse  her  fourth  while  on  a 
milk  diet  for  eighteen  months,  and  gained  while  doing  so  nineteen 
pounds.  Another  gained  sixty-five  pounds  while  nursing,  and  her  son 
was  very  large  for  his  age.  A  third  lost  a  child  by  hand-feeding,  and 
nursed  the  next  infant  on  a  milk  diet,  at  the  same  time  becoming  fatter 
than  she  had  ever  been.  A  decided  advantage  in  the  use  of  milk  is, 
that  it  prevents  the  exhausted  feeling  so  common  with  delicate  nursing 
mothers.  I  have  had  a  patient  of  eighty-six  pounds  weight  use  two 
quarts  of  milk  a  day,  and  at  the  same  time  eat  her  usual  measure  of 
food,  which  had  always  been  of  small  amount. — ED.] 

Depressed.  Nipples. — A  not  uncommon  source  of  difficulty  is  a 
depressed  condition  of  the  nipples,  which  is  generally  produced  by  the 
constant  pressure  of  the  stays.  The  result  is  that  the  child,  unable  to 
grasp  the  nipple,  and  wearied  with  ineffectual  efforts,  may  at  last  refuse 
the  breast  altogether.  An  endeavor  should  be  made  to  elongate  the 
nipple  before  putting  it  into  the  child's  mouth,  either  by  the  fingers  or 
by  some  form  of  breast-pump,  which  here  finds  a  useful  application. 
In  the  worst  class  of  cases,  when  the  nipple  is  permanently  depressed, 
it  may  be  necessary  to  let  the  child  suck  through  a  glass  nipple-shield, 
to  which  is  attached  an  India-rubber  tube  similar  to  that  of  a  sucking- 
bottle  ;  this  it  is  generally  well  able  to  do. 

Fissures  and  Excoriations  of  the  Nipples. — Fissures  and  excoria- 
tions of  the  nipples  are  common  causes  of  suffering,  in  some  cases 
leading  to  mammary  abscess.  Whenever  the  practitioner  has  the 
opportunity,  he  should  advise  his  patient  to  prepare  the  nipple  for 
nursing  in  the  latter  months  of  pregnancy ;  and  this  may  best  be  done 
by  daily  bathing  it  with  a  spirituous  or  astringent  lotion,  such  as  can 
de  Cologne  and  water  or  a  weak  solution  of  tannin.  After  nursing 

1  Kouili  on  Infant-feeding. 


MANAGEMENT    OF    THE    INFANT,    LACTATION,   ETC.      595 

has  begun  great  care  should  be  taken  to  wash  and  dry  the  nipple  after 
the  child  has  been  applied  to  it,  and,  as  long  as  the  mother  is  in  the 
recumbent  position,  siie  may,  if  tlie  nipples  be  at  all  tender,  use  zinc 
nipple-shields  with  advantage  when  she  is  not  nursing.  In  this  way 
these  troublesome  complications  may  generally  be  prevented.  The 
most  common  forms  are  either  an  abrasion  on  the  surface  of  the  nipple, 
which,  if  neglected,  may  form  a  small  ulcer,  or  a  crack  at  some  part 
of  the  nipple,  most  generally  at  its  base.  In  either  case,  the  suifering 
when  the  child  is  put  to  the  breast  is  intense,  sometimes  indeed  amount- 
ing to  intolerable  anguish,  causing  the  mother  to  look  forward  with 
dread  to  the  application  of  the  child.  Whenever  such  pain  is  com- 
plained of,  the  nipple  should  be  carefully  examined,  since  the  fissure 
or  sore  is  often  so  minute  as  to  escape  superficial  examination.  The 
remedies  recommended  are  very  numerous  and  not  always  successful. 
Amongst  those  most  commonly  used  are  astringent  applications,  such 
as  tannin  or  weak  solutions  of  nitrate  of  silver,  or  cauterizing  the 
edges  of  the  fissure  with  solid  nitrate  of  silver,  or  applying  the  flexible 
collodion  of  the  Pharmacopeia.  Dr.  AVilson,  of  Glasgow,  speaks 
highly  of  a  lotion  composed  of  ten  grains  of  nitrate  of  lead  in  an 
ounce  of  glycerin,  which  is  to  be  applied  after  suckling,  the  nipple 
being  carefully  washed  before  the  child  is  again  put  to  the  breast.  I 
.  have  myself  found  nothing  answer  so  well  as  a  lotion  composed  of 
half  an  ounce  of  sulphurous  acid,  half  an  ounce  of  the  glycerin  of 
tannin,  and  an  ounce  of  water,  the  beneficial  effects  of  which  are  some- 
times quite  remarkable.  Relief  may  occasionally  be  obtained  by 
inducing  the  child  to  suck  through  a  nipple-shield,  especially  when 
there  is  only  an  excoriation ;  but  this  will  not  always  answer,  on 
account  of  the  extreme  pain  which  it  produces. 

Excessive  Flow  of  Milk. — An  excessive  flow  of  milk,  known  as 
galadorrhcea,  often  interferes  with  successful  lactation.  It  is  by  no 
means  rare  in  the  first  weeks  after  delivery  for  women  of  delicate  con- 
stitutions who  are  really  unfit  to  nurse,  to  be  flooded  with  a  super- 
abundance of  watery  and  innutritions  milk,  which  soon  produces 
.disordered  digestion  in  the  child.  Under  such  circumstances  the  only 
thing  to  be  done  is  to  give  up  an  attempt  which  is  injurious  both  to 
the  mother  and  child.  At  a  later  stage  the  milk,  secreted  in  large 
quantities,  is  sufficiently  nourishing  to  the  child,  but  the  drain  on  the 
mother's  constitution  soon  begins  to  tell  on  her.  Palpitation,  giddi- 
ness, emaciation,  headache,  loss  of  sleep,  spots  before  the  eyes,  indicate 
the  serious  effects  which  are  being  produced,  and  the  absolute  necessity 
of  at  once  stopping  lactation.  Whenever,  therefore,  a  nursing-woman 
suffers  from  such  symptoms,  it  is  far  better  at  once  to  remove  the 
cause,  otherwise  a  very  serious  and  permanent  deterioration  of  health 
might  result.  When,  under  such  circumstances,  nursing  is  unwisely 
persevered  in,  most  serious  results  may  follow.  Should  any  diathetic 
tendency  exist,  especially  when  there  is  a  predisposition  to  phthisis, 
nothing  is  so  likely  to  develop  it  as  the  debility  produced  by  excessive 
lactation.  Certain  diseases  of  the  eye  are  then  specially  apt  to  occur, 
such  as  severe  inflammation  of  the  cornea,  leading  to  opacity  and  even 


596  THE    PUERPERAL    STATE. 

sloughing,  and  certain  forms  of  choroiditis ;  also  impairment  of  accom- 
modation due  to  defective  power  of  the  ciliary  muscle.1 

Mammary  Abscess. — There  is  no  more  troublesome  complication 
of  lactation  than  the  formation  of  abscess  in  the  breast ;  an  occurrence 
by  no  means  rare,  and  which,  if  improperly  treated,  may,  by  long- 
continued  suppuration  and  the  formation  of  numerous  sinuses  in  and 
about  the  breast,  produce  very  serious  effects  on  the  general  health. 
The  causes  of  breast  abscesses  are  numerous,  and  very  trivial  circum- 
stances may  occasionally  set  up  inflammation  ending  in  suppuration. 
Thus  it  may  follow  exposure  to  cold,  a  blow  or  other  injury  to  the 
breast,  some  temporary  engorgement  of  the  lacteal  tubes,  or  even 
sudden  or  depressing  mental  emotions.  The  most  frequent  cause  is 
irritation  from  fissures  or  erosions  of  the  nipple,  which  must  there- 
fore always  be  regarded  with  suspicion  and  cured  as  soon  as  possible. 

It  has  of  late  years  been  held  that  mammary  abscess  generally  arises 
from  septic  infection  through  such  fissures,  an  idea  first  suggested  by 
Kaltenbach.  Since  that  date  pyogenic  microbes  have  generally  been 
detected  in  puerperal  mammary  abscesses.  It  is  considered  possible 
that  infective  microbes  may  find  an  entrance  through  the  openings  of 
the  lactiferous  ducts,  when  no  fissures  exist.2  These  considerations 
obviously  point  to  the  necessity  of  extreme  care  and  cleanliness  in  ail 
nursing- women. 

The  abscess  may  form  in  any  part  of  the  breast,  or  in  the  areolar 
tissue  below  it ;  in  the  latter  case,  the  inflammation  very  generally 
extends  to  the  gland  structure.  Abscess  is  usually  ushered  in  by  con- 
stitutional symptoms,  varying  in  severity  with  the  amount  of  the 
inflammation.  Pyrexia  is  always  present ;  elevated  temperature,  rapid 
pulse,  and  much  malaise  and  sense  of  feverishness,  followed,  in  many 
cases,  by  distinct  rigor,  when  deep-seated  suppuration  is  taking  place. 
On  examining  the  breast  it  will  be  found  to  be  generally  enlarged  and 
very  tender,  while  at  the  site  of  the  abscess  an  indurated  and  painful 
swelling  may  be  felt.  If  the  inflammation  be  chiefly  limited  to  the 
sub-glandular  areolar  tissue,  there  may  be  no  localized  swelling  felt, 
but  the  whole  breast  will  be  acutely  sensitive  and  the  slightest  move- 
ment will  cause  much  pain.  As  the  case  progresses,  the  abscess 
becomes  more  and  more  superficial,  the  skin  covering  it  is  red  and 
glazed,  and  if  left  to  itself  it  bursts.  In  the  more  serious  cases  it  is 
by  no  means  rare  for  multiple  abscesses  to  form.  These,  opening  one 
after  the  other,  lead  to  the  formation  of  numerous  fistulous  tracts,  by 
which  the  breast  may  become  completely  riddled.  Sloughing  of  por- 
tions of  the  gland  tissue  may  take  place,  and  even  considerable  hemor- 
rhage from  the  destruction  of  bloodvessels.  The  general  health  soon 
suffers  to  a  marked  degree,  and,  as  the  sinuses  continue  to  suppurate 
for  many  successive  months,  it  is  by  no  means  uncommon  for  the 
patient  to  be  reduced  to  a  state  of  profound  and  even  dangerous 
debility. 

1  See  Foerster,  of  Breslau,  in  Graefe  and  Saemisch's  Handbuch  des  Gesammten  Augenheilkunde, 
and  Power  on  "  The  Diseases  of  the  Eye  in  Connection  with  Pregnancy,"  Lancet,  1880,  vol.  i..p. 
709  et  seq. 

2  See  Dr.  J.  Watt  Black's  Inaugural  Address,  Obstet.  Trans.,  vol.  xxxii.  p.  97. 


MANAGEMENT    OF    THE    INFANT,   LACTATION,   ETC.      597 

Treatment. — Much  may  be  done  by  proper  care  to  prevent  the 
formation  of  abscess,  especially  by  removing  engorgement  of  the  lacteal 
ducts,  when  threatened,  by  gentle  hand-friction  in  the  manner  already 
indicated.  When  the  general  symptoms  and  the  local  tenderness 
indicate  that  inflammation  has  commenced,  we  should  at  once  endeavor 
to  moderate  it,  in  the  hope  that  resolution  may  occur  without  the  for- 
mation of  pus.  Here  general  principles  must  be  attended  to,  especially 
giving  the  affected  part  as  much  rest  as  possible.  Feverishness  may 
be  combated  by  gentle  salines,  minute  doses  of  aconite,  and  large  doses 
of  quinine ;  while  pain  should  be  relieved  by  opiates.  The  patient 
should  be  strictly  confined  in  bed,  and  the  affected  breast  supported  by 
a  suspensory  bandage.  Warmth  and  moisture  are  the  best  means  of 
relieving  the  local  pain,  either  in  the  form  of  hot  fomentations  or  of 
light  poultices  of  linseed-meal  or  bread  and  milk,  and  the  breast  may 
be  smeared  with  extract  of  belladonna  rubbed  down  with  glycerin,  or 
the  belladonna  liniment  sprinkled  over  the  surface  of  the  poultices. 
The  local  application  of  ice  in  India-rubber  bags  has  been  highly  ex- 
tolled as  a  means  of  relieving  the  pain  and  tension,  and  it  is  said  to 
be  much  more  effectual  than  heat  and  moisture.1  Generally  the  pain 
and  irritation  produced  by  putting  the  child  to  the  breast  are  so  great 
as  to  centra-indicate  nursing  from  the  affected  side  altogether,  and  we 
must  trust  to  relieving  the  tension  by  poultices ;  suckling  being,  in  the 
meantime,  carried  on  at  the  other  breast  alone.  In  favorable  cases 
this  is  quite  possible  for  a  time,  and  it  may  be  that,  if  the  inflammation 
do  not  end  in  suppuration,  or  if  the  abscess  be  small  and  localized,  the 
affected  breast  is  again  able  to  resume  its  functions.  Often  this  is  not 
possible,  and  it  may  be  advisable,  in  severe  cases,  to  give  up  nursing 
altogether. 

The  subsequent  management  of  the  case  consists  in  the  opening  of 
the  abscess  as  soon  as  the  existence  of  pus  is  ascertained,  either  by 
fluctuation,  or,  if  the  site  of  the  abscess  be  deep-seated,  by  the  exploring- 
needle.  It  may  be  laid  down  as  a  principle,  that  the  sooner  the  pus 
is  evacuated  the  better,  and  nothing  is  to  be  gained  by  waiting  until 
it  is  superficial.  On  the  contrary,  such  delay  only  leads  to  more 
extensive  disorganization  of  tissue,  and  the  further  spread  of  inflam- 
mation. 

The  method  of  opening-  the  abscess  is  of  primary  importance. 
Care  should  be  taken  to  make  the  incision  in  a  line  radiating  from  the 
nipple,  so  as  to  avoid  cutting  across  the  ducts.  It  has  formerly  been 
customary  simply  to  open  the  abscess  at  its  most  dependent  part, 
without  using  any  precaution  against  the  admission  of  air,  and  after- 
ward to  treat  secondary  abscesses  in  the  same  way.  The  results  are 
well  known  to  all  practical  accoucheurs,  and  the  records  of  surgery 
fully  show  how  many  weeks  or  months  generally  elapse  in  bad  cases 
before  recovery  is  complete.  The  antiseptic  treatment  of  mammary 
abscess,  in  the  way  first  pointed  out  by  Lister,  affords  results  which 
are  of  the  most  remarkable  and  satisfactory  kind.  Instead  of  being 
weeks  and  months  in  healing,  I  believe  that  the  practitioner  who  fairly 

.  !  Corson!:  Amer.  Journ.  of  Obstet.,  1881,  vol.  xiv.  p.  48. 


598  THE    PUERPERAL    STATE. 

and  minutely  carries  out  Sir  Joseph  Lister's  directions  may  confidently 
look  for  complete  closure  of  the  abscess  in  a  few  days ;  and  I  know 
nothing  in  the  whole  range  of  my  professional  experience  that  has 
given  me  more  satisfaction  than  the  application  of  this  method  to 
abscesses  of  the  breast.  The  plan  I  first  used  is  that  recommended  by 
Lister  in  the  Lancet  for  1867,  but  which  is  now  superseded  by  his  im- 
proved methods,  which,  of  course,  will  be  used  in  preference  by  all 
who  have  made  themselves  familiar  with  the  details  of  antiseptic  sur- 
gery. The  former,  however,  is  easily  within  the  reach  of  everyone, 
and  is  so  simple  that  no  special  skill  or  practice  is  required  in  its 
application ;  whereas  the  more  perfected  antiseptic  appliances  will 
probably  not  be  so  readily  obtained,  and  are  much  more  difficult  to 
use.  I  therefore  insert  Sir  Joseph  Lister's  original  directions,  which 
he  assures  me  are  perfectly  antiseptic,  for  the  guidance  of  those  who 
may  not  be  able  to  obtain  the  more  elaborate  dressings  :  "  A  solution 
of  one  part  of  crystallized  carbolic  acid  in  four  parts  of  boiled  linseed 
oil  having  been  prepared,  a  piece  of  rag  from  four  to  six  inches  square 
is  dipped  into  the  oily  mixture  and  laid  upon  the  skin  where  the  inci- 
sion is  to  be  made.  The  lower  edge  of  the  rag  being  then  raised,  while 
the  upper  edge  is  kept  from  slipping  by  an  assistant,  a  common 
scalpel  or  bistoury  dipped  in  the  oil  is  plunged  into  the  cavity  of  the 
abscess,  and  an  opening  about  three-quarters  of  an  inch  in  length  is 
made,  and  the  instant  the  knife  is  withdrawn  the  rag  is  dropped  upon 
the  skin  as  an  antiseptic  curtain,  beneath  which  the  pus  flows  out  into 
a  vessel  placed  to  receive  it.  The  cavity  of  the  abscess  is  firmly 
pressed,  so  as  to  force  out  all  existing  pus  as  nearly  as  may  be  (the  old 
fear  of  doing  mischief  by  rough  treatment  of  the  pyogenic  membrane 
being  quite  ill-founded) ;  and  if  there  be  much  oozing  of  blood,  or  if 
there  be  considerable  thickness  of  parts  between  the  abscess  and  the 
surface,  a  piece  of  lint  dipped  in  the  antiseptic  oil  is  introduced  into 
the  incision  to  check  bleeding  and  prevent  primary  adhesion,  which  is 
otherwise  very  apt  to  occur.  The  introduction  of  the  lint  is  effected 
as  rapidly  as  may  be,  and  under  the  protection  of  the  antiseptic  rag. 
Thus  the  evacuation  of  the  original  contents  is  accomplished  with  per- 
fect security  against  the  introduction  of  living  germs.  This,  however, 
would  be  of  no  avail  unless  an  antiseptic  dressing  could  be  applied 
that  would  effectually  prevent  the  decomposition  of  the  stream  of  pus 
constantly  flowing  out  beneath  it.  After  numerous  disappointments, 
I  have  succeeded  with  the  following,  wrhich  may  be  relied  upon  as  abso- 
lutely trustworthy  :  About  six  teaspoonfuls  of  the  above-mentioned  solu- 
tion of  carbolic  acid  in  linseed  oil  are  mixed  up  with  common  whiting 
(carbonate  of  lime)  to  the  consistence  of  a  firm  paste,  which  is,  in  fact, 
glazier's  putty  with  the  addition  of  a  little  carbolic  acid.  This  is 
spread  upon  a  piece  of  common  tinfoil  about  six  inches  square,  so  as 
to  form  a  layer  about  a  quarter  of  an  inch  thick.  The  tinfoil,  thus 
spread  with  putty,  is  placed  upon  the  skin,  so  that  the  middle  of  it 
corresponds  to  the  position  of  the  incision,  the  antiseptic  rag  used  in 
opening  the  abscess  being  removed  the  instant  before.  The  tin  is  then 
fixed  securely  by  adhesive  plaster,  the  lowest  edge  being  left  free  for 
the  escape  of  the  discharge  into  a  folded  towel  placed  over  it  and 


MANAGEMENT    OF    THE    INFANT,   LACTATION,   ETC.      599 

secured  by  a  bandage.  The  dressing  is  changed,  as  a  general  rule, 
once  in  twenty-four  hours,  but,  if  the  abscess  be  a  very  large  one,  it  is 
prudent  to  see  the  patient  twelve  hours  after  it  has  been  opened,  when, 
if  the  towel  should  be  much  stained  with  discharge,  the  dressing  should 
be  changed,  to  avoid  subjecting  its  antiseptic  virtues  to  too  severe  a 
test.  But  after  the  first  twenty-four  hours  a  single  daily  dressing  is 
sufficient.  The  changing  of  the  dressing  must  be  methodically  done 
as  follows :  A  second  similar  piece  of  tinfoil  having  been  spread  with 
the  putty,  a  piece  of  rag  is  dipped  in  the  oily  solution  and  placed  on 
the  incision  the  moment  the  first  tin  is  removed.  This  guards  against 
the  possibility  of  mischief  occurring  during  the  cleansing  of  the  skin 
with  a  dry  cloth,  and  pressing  out  any  discharge  which  may  exist  in 
the  cavity.  If  a  plug  of  lint  was  introduced  when  the  abscess  was 
opened,  it  is  removed  under  cover  of  the  antiseptic  rag,  which  is  taken 
off  at  the  moment  when  the  new  tin  is  to  be  applied.  The  same  pro- 
cess is  continued  daily  until  the  sinus  closes." 

Treatment  of  Long-continued.  Suppuration. — If  the  case  come 
under  our  care  when  the  abscess  has  been  long  discharging,  or  when 
sinuses  have  formed,  the  treatment  is  directed  mainly  to  procuring  a 
cessation  of  suppuration  and  closure  of  the  sinuses.  For  this  purpose 
methodical  strapping  of  the  breast  with  adhesive  plaster,  so  as  to  afford 
steady  support  and  compress  the  opposing  pyogenic  surfaces,  will  give 
the  best  results.  It  may  be  necessary  to  lay  open  some  of  the  sinuses, 
or  to  inject  tinct.  iodi  or  other  stimulating  lotions,  so  as  to  moderate 
the  discharge,  the  subsequent  surgical  treatment  varying  according  to 
the  requirements  of  each  case.  In  such  neglected  cases  Billroth  recom- 
mends that,  after  the  patient  has  been  anaesthetized,  the  openings 
should  be  dilated  so  as  to  admit  the  finger,  by  which  the  septa  between 
the  various  sinuses  should  be  broken  down  and  a  large  single  abscess- 
cavity  made.  This  should  then  be  thoroughly  irrigated  with  a  3  per 
cent,  solution  of  carbolic  acid,  a  drainage-tube  introduced,  and  the 
ordinary  antiseptic  dressings  applied.  As  the  drain  on  the  system  is 
great,  and  the  constitutional  debility  generally  pronounced,  much  atten- 
tion must  be  paid  to  general  treatment ;  and  abundance  of  nourishing 
food,  appropriate  stimulants,  and  such  medicines  as  iron  and  quinine, 
will  be  indicated. 

Hand-feeding. — In  a  considerable  number  of  cases  the  inability  of 
the  mother  to  nurse  her  child,  her  invincible  repugnance  to  a  wet- 
nurse,  or  inability  to  bear  the  expense,  renders  hand-feeding  essential. 
It  is,  therefore,  of  importance  that  the  accoucheur  should  be  thoroughly 
familiar  with  the  best  method  of  bringing  up  the  child  by  hand,  so  as 
to  be  able  to  direct  the  process  in  the  way  that  is  most  likely  to  be 
successful. 

Much  of  the  mortality  following  hand-feeding  may  be  traced  to 
unsuitable  food.  Among  the  poorer  classes  especially  there  is  a 
prevalent  notion  that  milk  alone  is  insufficient ;  and  hence  the  almost 
universal  custom  of  administering  various  farinaceous  foods,  such  as 
corn-flour  or  arrowroot,  even  from  the  earliest  period.  Many  of  these 
consist  of  starch  alone,  and  are  therefore  absolutely  uusuited  for 
forming  the  staple  of  diet,  on  account  of  the  total  absence  of  nitro- 


600  THE    PUERPERAL    STATE. 

genized  elements.  Independently  of  this,  it  has  been  shown  that  the 
saliva  of  infants  has  not  the  same  digestive  property  on  starch  that 
it  subsequently  acquires,  and  this  affords  a  further  explanation  of  its 
so  constantly  producing  intestinal  derangement.  Reason  as  well  as 
experience  abundantly  proves  that  the  object  to  be  aimed  at  in  hand- 
feeding  is  to  imitate  as  nearly  as  possible  the  food  which  Nature  sup- 
plies for  the  newborn  child,  and,  therefore,  the  obvious  course  is  to  use 
milk  from  some  animal,  so  treated  as  to  make  it  resemble  human  milk 
as  nearly  as  may  be. 

Of  the  various  milks  used,  that  of  the  ass,  on  the  whole,  most  closely 
resembles  human  milk,  containing  less  casein  and  butter,  and  more 
saline  ingredients.  It  is  not  always  easy  to  obtain,  and  in  towns  it  is 
excessively  expensive.  Moreover,  it  does  not  always  agree  with  the 
child,  being  apt  to  produce  diarrhoea.  We  can,  however,  be  more 
certain  of  its  being  unadulterated,  which  in  large  cities  is  in  itself  no 
small  advantage,  and  it  may  be  given  without  the  addition  of  water 
or  sugar. 

Goat's  milk  in  England  is  still  more  difficult  to  obtain,  but  it  often 
succeeds  admirably.  In  many  places  the  infant  sucks  the  teat  directly, 
and  certainly  thrives  well  on  this  plan. 

Cow's  Milk  and  its  Preparation. — In  a  large  majority  of  cases  we 
have  to  rely  on  cow's  milk  alone.  It  differs  from  human  milk  in  con- 
taining less  water,  a  larger  amount  of  casein  and  solid  matters,  and  less 
sugar.  Therefore,  before  being  given  it  requires  to  be  diluted  and 
sweetened.  A  common  mistake  is  over-dilution,  and  it  is  far  from 
rare  for  nurses  to  administer  one-third  cow's  milk  to  two-thirds  water. 
The  result  of  this  excessive  dilution  is,  that  the  child  becomes  pale  and 
puny,  and  has  none  of  the  firm  and  plump  appearance  of  a  well-fed 
infant.  The  practitioner  should,  therefore,  ascertain  that  this  mistake 
is  not  being  made ;  and  the  necessary  dilution  will  be  best  obtained  by 
adding  to  pure  fresh  cow's  milk  one-third  hot  water,  so  as  to  warm 
the  mixture  to  about  96°,  the  whole  being  slightly  sweetened  with 
sugar  of  milk  or  ordinary  crystallized  sugar.  After  the  first  two  or 
three  months  the  amount  of  water  may  be  lessened,  and  pure  milk, 
warmed  and  sweetened,  given  instead.  Whenever  it  is  possible,  the 
milk  should  be  obtained  from  the  same  cow,  and  in  towns  some  care 
is  requisite  to  see  that  the  animal  is  properly  fed  and  stabled.  Of  late 
years  it  has  been  customary  to  obviate  the  difficulties  of  obtaining  good 
fresh  milk  by  using  some  of  the  canned  milks  now  so  easily  to  be  had. 
These  are  already  sweetened,  and  sometimes  answer  well  if  not  given 
in  too  weak  a  dilution.  One  great  drawback  in  bottle-feeding  is  the 
tendency  of  the  milk  to  become  acid,  and  hence  to  produce  diarrhoea. 
This  may  be  obviated  to  a  great  extent  by  adding  a  tablespoonful  of 
lime-water  to  each  bottle,  instead  of  an  equal  quantity  of  water. 

Artificial  Human  Milk. — An  admirable  plan  of  treating  cow's 
milk,  so  as  to  reduce  it  to  almost  absolute  chemical  identity  with 
human  milk,  has  been  devised  by  Professor  Fraukland,  to  whom  I 
am  indebted  for  permission  to  insert  the  recipe.  I  have  followed  this 
method  in  many  cases,  and  find  it  far  superior  to  the  usual  one,  as  it 
produces  an  exact  and  uniform  compound.  With  a  little  practice 


MANAGEMENT    OF    THE    INFANT,   LACTATION,   ETC.      601 

nurses  can  make  it  with  no  more  trouble  than  the  ordinary  mixing  of 
cow's  milk  with  water  and  sugar.  The  following  extract  from  Dr. 
Fraukland's  work1  will  explain  the  principles  on  which  the  prepara- 
tion of  the  artificial  human  milk  is  founded:  "The  rearing  of  infants 
who  cannot  be  supplied  with  their  natural  food  is  notoriously  difficult 
and  uncertain,  owing  chiefly  to  the  great  difference  in  the  chemical 
composition  of  human  milk  and  cow's  milk.  The  latter  is  much  richer 
in  casein  and  poorer  in  milk-sugar  than  the  former,  whilst  ass's  milk, 
which  is  sometimes  used  for  feeding  infants,  is  too  poor  in  casein  and 
butter,  although  the  proportion  of  sugar  is  nearly  the  same  as  in  human 
milk.  The  relations  of  the  three  kinds  of  milk  to  each  other  are  clearly 
seen  from  the  following  analytical  numbers,  which  express  the  per- 
centage amounts  of  the  different  constituents  : 

Woman.  Ass.  Cow. 

Casein 2.7  1.7  4.2 

Butter 3.5  1.3  3.8 

Milk-sugar .                5.0  4.5  3.8 

Salts 0.2  0.5  0.7 

These  numbers  show  that  by  the  removal  of  one-third  of  the  casein 
from  cow's  milk  and  the  addition  of  about  one-third  more  milk-sugar, 
a  liquid  is  obtained  which  closely  approaches  human  milk  in  composi- 
tion, the  percentage  amounts  of  the  four  chief  constituents  being  as 
follows : 

Casein 2.8 

Butter H.S 

Milk-sugar 50 

Salts 0.7 

The  following  is  the  mode  of  preparing  the  milk  :  Allow  one-third  of 
a  pint  of  new  milk  to  stand  for  about  twelve  hours,  remove  the  cream, 
and  to  the  latter  add  two-thirds  of  a  pint  of  new  milk,  as  fresh  from 
the  cow  as  possible.  Into  the  one-third  of  a  pint  of  blue  milk  left 
after  the  abstraction  of  the  cream  put  a  piece  of  rennet  about  one  inch 
square.  Set  the  vessel  in  warm  water  until  the  milk  is  fully  curdled, 
an  operation  requiring  from  five  to  fifteen  minutes  according  to  the 
activity  of  the  rennet,  which  should  be  removed  as  soon  as  the  curdling 
commences  and  put  into  an  egg-cup  for  use  on  subsequent  occasions, 
as  it  may  be  employed  daily  for  a  month  or  two.  Break  up  the  curd 
repeatedly ,  and  carefully  separate  the  whole  of  the  whey,  which  should 
then  be  rapidly  heated  to  boiling  in  a  small  tin  pan  placed  over  a 
spirit  or  gas  lamp.  During  the  heating  a  further  quantity  of  casein, 
technically  called  'fleetings/  separates,  and  must  be  removed  by 
straining  through  muslin.  Now  dissolve  110  grains  of  powdered 
sugar  of  milk  in  the  hot  whey,  and  mix  it  with  the  two-thirds  of  a 
pint  of  new  milk  to  which  the  cream  from  the  other  third  of  a  pint 
was  added  as  already  described.  The  artificial  milk  should  be  used 
within  twelve  hours  of  its  preparation,  and  it  is  almost  needless  to 
add  that  all  the  vessels  employed  in  its  manufacture  and  administra- 
tion should  be  kept  scrupulously  clean."2 

1  Frankland's  Experimental  Researches  in  Chemistry,  p.  843. 

2  The  following  recipe  yields  the  same  results,  but  the  method  is  easier,  and  I  find  that  nurses 
prepare  the  milk  with  less  difficulty  when  it  is  followed  :  "  Heat  half  a  pint  of  skimmed  milk  to 
about  96°,  that  is,  just  warm,  and  well  stir  into  the  warmed  milk  a  measure  full  of  Walden's 


602  THE    PUERPERAL    STATE. 

Method  of  Hand-feeding. — Much  of  the  success  of  bottle-feeding 
must  depend  on  minute  care  and  scrupulous  cleanliness,  points  which 
cannot  be  too  strongly  insisted  on.  Particular  attention  should  be 
paid  to  preparing  the  food  fresh  for  every  meal,  and  to  keeping  the 
feeding  bottle  and  tubes  constantly  in  water  when  not  in  use,  so  that 
minute  particles  of  milk  may  not  remain  about  them  and  become  sour. 
A  neglect  of  this  is  one  of  the  most  fertile  sources  of  the  thrush  from 
which  bottle-fed  infants  often  suffer.  The  particular  form  of  bottle 
used  is  not  of  much  consequence.  Those  now  commonly  employed, 
with  a  long  India-rubber  tube  attached,  are  preferable  to  the  older 
forms  of  flat  bottle,  as  they  necessitate  strong  suction  on  the  part  of 
the  infant,  thus  forcing  it  to  swallow  the  food  more  slowly.  Care 
must  be  taken  to  give  the  meals  at  stated  periods,  as  in  breast-feeding, 
and  these  should  be  at  first  about  two  hours  apart,  the  intervals  being 
gradually  extended.  The  nurse  should  be  strictly  cautioned  against 
the  common  practice  of  placing  the  bottle  beside  the  infant  in  its 
cradle  and  allowing  it  to  suck  to  repletion — a  practice  which  leads  to 
over-distention  of  the  stomach  and  consequent  dyspepsia.  The  child 
should  be  raised  in  the  arms  at  the  proper  time,  have  its  food  admin- 
istered, and  then  replaced  in  the  cradle  to  sleep.  In  the  first  few 
weeks  of  bottle-feeding  constipation  is  very  common,  and  may  be 
effectually  remedied  by  placing  as  much  phosphate  of  soda  as  will  lie 
on  a  threepenny-piece  in  the  bottle,  two  or  three  times  in  the  twenty- 
four  hours. 

Other  Kinds  of  Pood. — If  this  system  succeed,  no  other  food  should 
be  given  until  the  child  is  six  or  seven  months  old,  and  then  some  of 
the  various  infants'  foods  may  be  cautiously  commenced.  Of  these 
there  are  an  immense  number  in  common  use,  some  of  which  are  good 
articles  of  diet,  others  are  unfitted  for  infants.  In  selecting  them  we 
have  to  see  that  they  contain  the  essential  elements  of  nutrition  in 
proper  combination.  All  those,  therefore,  that  are  purely  starchy  in 
character,  such  as  arrowroot,  corn-flour,  and  the  like,  should  be 
avoided ;  while  those  that  contain  nitrogenous  as  well  as  starch  ele- 
ments may  be  safely  given.  Of  the  latter  the  entire  wheat-flour, 
which  contains  the  husks  ground  down  with  the  wheat,  generally 
answers  admirably ;  and  of  the  same  character  are  rusks,  tops  and 
bottoms,  Nestle's  or  Liebig's  infants'  food,  and  many  others.  If  the 
child  be  pale  and  flabby,  some  more  purely  animal  food  may  often  be 
given  twice  a  day,  and  great  benefit  may  be  derived  from  a  single 
meal  of  beef,  chicken,  or  veal  tea,  with  a  little  bread-crumb  in  it, 
especially  after  the  sixth  or  seventh  month.  Milk,  however,  should 
still  form  the  main  article  of  diet,  and  should  continue  to  do  so  for 
many  months. 

Management  when  Milk  Disagrees. — If  the  child  be  pale,  flabby, 
and  do  not  gain  flesh,  more  especially  if  diarrhoea  or  other  intestinal 
disturbance  be  present,  we  may  be  certain  that  hand-feeding  is  not 

extract  of  rennet.  When  It  is  set,  break  up  the  curd  quite  small,  and  let  it  stand  for  ten  or  fifteen 
minutes,  when  the  curd  will  sink ;  then  place  the  whey  in  a  saucepan  and  boil  quickly.  In  a  third 
of  a  pint  of  this  whey  dissolve  a  heaped-up  teaspoonftil  of  sugar  of  milk.  When  quite  cold,  add  two- 
thirds  of  a  pint  of  new  milk  and  two  teaspoonfuls  of  cream,  well  stirring  the  whole  together.  If 
during  the  first  month  the  milk  is  too  rich,  use  rather  more  than  a  third  of  a  pint  of  whey." 


PUERPERAL    ECLAMPSIA.  603 

answering  satisfactorily,  and  that  some  change  is  required.  If  the 
child  be  not  too  old,  and  will  still  take  the  breast,  that  is  certainly 
the  best  remedy,  but  if  that  be  not  possible,  it  is  necessary  to  alter  the 
diet.  When  milk  disagrees,  cream,  in  the  proportion  of  one  table- 
spoonful  to  three  of  water,  sometimes  answers  as  well.  Occasionally 
also  Liebig's  or  Mellin's  infants'  food,  when  carefully  prepared,  ren- 
ders good  service.  Too  often,  however,  when  once  diarrhoea  or  other 
intestinal  disturbance  has  set  in,  all  our  efforts  may  prove  unavailing, 
and  the  health,  if  not  the  life,  of  the  infant  becomes  seriously  im- 
perilled. It  is  not,  however,  within  the  scope  of  this  work  to  treat  of 
the  disorders  of  infants  at  the  breast,  the  proper  consideration  of 
which  requires  a  large  amount  of  space,  and  I  therefore  refrain  from 
making  any  further  remarks  on  the  subject. 


CHAPTER   III. 

PUERPERAL  ECLAMPSIA. 

Puerperal  Eclampsia. — By  the  term  puerperal  eclampsia  is  meant 
a  peculiar  kind  of  epileptiform  convulsions,  which  may  occur  in  the 
latter  months  of  pregnancy,  or  during  or  after  parturition,  and  it  con- 
stitutes one  of  the  most  formidable  diseases  with  which  the  obstetrician 
has  to  cope.  The  attack  is  often  so  sudden  and  unexpected,  so  terrible 
in  its  nature,  and  attended  with  such  serious  danger  both  to  the 
mother  and  child,  that  the  disease  has  attracted  much  attention. 

Its  Doubtful  Etiology. — The  researches  of  Lever,  Braun,  Frerichs, 
and  many  other  writers  who  have  shown  the  frequent  association  of 
eclampsia  with  albuminuria,  have  of  late  years  been  supposed  to 
clear  up  to  a  great  extent  the  etiology  of  the  disease  and  to  prove  its 
dependence  on  the  retention  of  urinary  elements  in  the  blood.  While 
the  urinary  origin  of  eclampsia  has  been  pretty  generally  accepted, 
more  recent  observations  have  tended  to  throw  doubt  on  its  essential 
dependence  on  this  cause ;  so  that  it  can  hardly  be  said  that  we  are 
yet  in  a  position  to  explain  its  true  pathology  with  certainty.  These 
points  will  require  separate  discussion,  but  it  is  first  necessary  to 
describe  the  character  and  history  of  the  attack. 

Considerable  confusion  exists  in  the  description  of  puerperal  con- 
vulsions from  the  confounding  of  several  essentially  distinct  diseases 
under  the  same  name.  Thus'  in  most  obstetric  works  it  has  been 
customary  to  describe  three  distinct  classes  of  convulsion,  the  epileptic, 
the  hysterical,  and  the  apoplectic.  The  two  latter,  however,  come 
under  a  totally  different  category.  A  pregnant  woman  may  suffer 
from  hysterical  paroxysms,  or  she  may  be  attacked  with  apoplexy 


604  THE    PUERPERAL    STATE. 

accompanied  with  coma  and  followed  by  paralysis.  But  these  con- 
ditions in  the  pregnant  or  parturient  woman  are  identical  with  the 
same  diseases  in  the  non-pregnant,  and  are  in  no  way  special  in  their 
nature.  True  eclampsia,  however,  is  different  in  its  clinical  history 
from  epilepsy,  although  the  paroxysms  while  they  last  are  essentially 
the  same  as  those  of  an  ordinary  epileptic  fit. 

Premonitory  Symptoms. — An  attack  of  eclampsia  seldom  occurs 
without  having  been  preceded  by  certain  more  or  less  well  marked 
precursory  symptoms.  It  is  true  that  in  a  considerable  number  of 
cases  these  are  so  slight  as  not  to  attract  attention,  and  suspicion  is  not 
aroused  until  the  patient  is  seized  with  convulsions.  Still,  subsequent 
investigations  will  very  generally  show  that  some  symptoms  did  exist, 
which,  if  observed  and  properly  interpreted,  might  have  put  the  prac- 
titioner on  his  guard,  and  possibly  have  enabled  him  to  ward  oif  the 
attack.  Hence  a  knowledge  of  them  is  of  real  practical  value.  The 
most  common  are  associated  with  the  cerebrum,  such  as  severe  head- 
ache, which  is  the  one  most  generally  observed,  and  is  sometimes 
limited  to  one  side  of  the  head.  Transient  attacks  of  dizziness,  spots 
before  the  eyes,  loss  of  sight,  or  impairment  of  the  intellectual  faculties 
are  also  not  uncommon.  These  signs  in  a  pregnant  woman  are  of  the 
gravest  import,  and  should  at  once  call  for  investigation  into  the 
nature  of  the  case.  Less  marked  indications  sometimes  exist  in  the 
form  of  irritability,  slight  headache  or  stupor,  and  a  geneal  feeling  of 
indisposition.  Another  important  premonitory  sign  is  oedema  of  the 
subcutaneous  cellular  tissue,  especially  of  the  face  or  upper  extremities, 
which  should  at  once  lead  to  an  examination  of  the  urine. 

Whether  such  indications  have  preceded  an  attack  or  not,  as  soon 
as  the  convulsion  comes  on  there  can  no  longer  be  any  doubt  as  to  the 
nature  of  the  case.  The  attack  is  generally  sudden  in  its  onset,  and 
in  its  character  is  precisely  that  of  a  severe  epileptic  fit  or  of  con- 
vulsions in  children.  Close  observation  shows  that  there  is  at  first  a 
short  period  of  tonic  spasm  affecting  the  entire  muscular  system. 
This  is  almost  immediately  succeeded  by  violent  clonic  contractions, 
generally  commencing  in  the  muscles  of  the  face,  which  twitch 
violently;  the  expression  is  horribly  altered,  the  globes  of  the  eyes  are 
turned  up  under  the  eyelids,  so  as  to  leave  only  the  white  sclerotics 
visible,  and  the  angles  of  the  mouth  are  retracted  and  fixed  in  a  con- 
vulsive grin.  The  tongue  is  at  the  same  time  protruded  forcibly,  and, 
if  care  be  not  taken,  is  apt  to  be  lacerated  by  the  violent  grinding  of 
the  teeth.  The  face,  at  first  pale,  soon  becomes  livid  and  cyanosed, 
while  the  veins  of  the  neck  are  distended,  and  the  carotids  beat  vigor- 
ously. Frothy  saliva  collects  about  the  mouth,  and  the  whole  appear- 
ance is  so  changed  as  to  render  the  patient  quite  unrecognizable.  The 
convulsive  movements  soon  attack  the  muscles  of  the  body.  The  hands 
and  arms,  at  first  rigidly  fixed,  with  the  thumbs  clenched  into  the 
palms,  begin  to  jerk,  and  the  whole  muscular  system  is  thrown  into 
rapidly  recurring  convulsive  spasms.  It  is  evident  that  the  involun- 
tary muscles  are  implicated  in  the  convulsive  action  as  well  as  the 
voluntary.  This  is  shown  by  a  temporary  arrest  of  respiration  at 
the  commencement  of  the  attack,  followed  by  irregular  and  hurried 


PUERPERAL    ECLAMPSIA.  605 

respiratory  movements  producing  a  peculiar  hissing  sound.  The 
occasional  involuntary  expulsion  of  urine  and  feces  indicates  the 
same  fact.  During  the  attack  the  patient  is  absolutely  unconscious, 
sensibility  is  totally  suspended,  and  she  has  afterward  no  recollection 
of  what  has  taken  place.  Fortunately  the  convulsion  is  not  of  long 
duration,  and  at  the  outside  does  not  last  more  than  three  or  four 
minutes,  generally  not  so  long,  and  it  has  been  pointed  out  that  a 
longer  paroxysm  would  almost  necessarily  prove  fatal  on  account  of 
the  implication  of  the  respiratory  muscles.  In  most  cases,  after  an 
interval  there  is  a  recurrence  of  the  convulsion  characterized  by  the 
same  phenomena,  and  the  paroxysms  are  repeated  with  more  or  less 
force  and  frequency  according  to  the  severity  of  the  attack.  Sometimes 
several  hours  may  elapse  before  a  second  convulsion  comes  on ;  at 
others  the  attacks  may  recur  very  often,  with  only  a  few  minutes 
between  them.  In  the  slighter  forms  of  eclampsia  there  may  not  be 
more  than  two  or  three  paroxysms  in  all ;  in  the  more  serious  as  many 
as  fifty  or  sixty  haye  been  recorded. 

Condition  between  the  Attacks. — After  the  first  attack  the 
patient  generally  soon  recovers  her  consciousness,  being  somewhat 
dazed  and  somnolent,  with  no  clear  conception  of  what  has  occurred. 
If  the  paroxysms  be  frequently  repeated,  more  or  less  profound  coma 
continues  in  the  intervals  between  them,  which  no  doubt  depends 
upon  intense  cerebral  congestion,  resulting  from  interference  with  the 
circulation  in  the  great  veins  of  the  neck,  produced  by  spasmodic  con- 
traction of  the  muscles.  The  coma  is  rarely  complete,  the  patient 
showing  signs  of  sensibility  when  irritated,  and  groaning  during  the 
uterine  contractions.  In  the  worst  class  of  cases  the  torpor  may 
become  intense  and  continuous,  and  in  this  state  the  patient  may  die. 
AVhen  the  convulsions  have  entirely  stopped,  and  the  patient  has  com- 
pletely regained  her  consciousness  and  is  apparently  convalescent, 
recollection  of  what  has  taken  place  during  and  some  time  before  the 
attack  may  be  entirely  lost,  and  this  condition  may  last  for  a  con- 
siderable time.  A  curious  instance  of  this  once  came  under  my  notice 
in  a  lady  who  had  lost  her  brother,  to  \vhom  she  was  greatly  attached, 
in  the  week  immediately  preceding  her  confinement,  and  in  whom  the 
mental  distress  seemed  to  have  had  a  great  deal  to  do  in  determining 
the  attack.  It  was  many  weeks  before  she  recovered  her  memory, 
and  during  that  time  she  recollected  nothing  about  the  circumstances 
connected  with  her  brother's  death,  the  whole  of  that  week  being,  as 
it  were,  blotted  out  of  her  recollection. 

Relation  of  the  Attacks  to  Labor. — If  the  convulsions  come  on 
during  pregnancy,  we  may  look  upon  the  advent  of  labor  as  almost  a 
certainty ;  and  if  we  consider  the  severe  nervous  shock  and  general 
disturbance,  this  is  the  result  we  might  reasonably  anticipate.  If  they 
occur,  as  is  not  uncommon,  for  the  first  time  during  labor,  the  pains 
generally  continue  with  increased  force  and  frequency,  since  the  uterus 
partakes  of  the  convulsive  action.  It  has  not  rarely  happened  that 
the  pains  have  gone  on  Avith  such  intensity  that  the  child  has  been 
born  quite  unexpectedly,  the  attention  of  the  practitioner  being  taken 
up  with  the  patient.  In  many  cases  the  advent  of  fresh  paroxysms  is 


606  THE    PUERPERAL    STATE. 

associated  with  the  commencement  of  a  pain,  the  irritation  of  which 
seems  sufficient  to  bring  on  the  convulsion. 

Results  to  the  Mother  and  Child. — The  results  of  eclampsia  vary 
according  to  the  severity  of  the  paroxysms.  It  is  generally  said  that 
about  one  in  three  or  four  cases  dies.  The  mortality  has  certainly 
lessened  of  late  years,  probably  in  consequence  of  improved  knowledge 
of  the  nature  of  the  disease  and  more  rational  modes  of  treatment. 
This  is  wTell  shown  by  Barker,1  who  found  in  1885  a  mortality  of  32 
per  cent,  in  cases  occurring  before  and  during  labor,  and  22  per  cent, 
in  those  after  labor ;  while  since  that  date  the  mortality  has  fallen  to 
14  per  cent.  The  same  conclusion  is  arrived  at  by  Dr.  Phillips,2  who 
has  shown  that  the  mortality  has  greatly  lessened  since  the  practice  of 
repeated  and  indiscriminate  bleeding,  long  considered  the  sheet-anchor 
in  the  disease,  has  been  discontinued  and  the  administration  of  chloro- 
form substituted. 

Cause  of  Death. — Death  may  occur  during  the  paroxysm,  and  then 
it  may  be  due  to  the  long  continuance  of  the  tonic  spasm  producing 
asphyxia.  It  is  certain  that,  as  long  as  the  tonic  spasm  lasts,  the 
respiration  is  suspended,  just  as  in  the  disease  of  children  known 
as  laryngismus  stridulus ;  and  it  is  possible  also  that  the  heart  may 
share  in  the  convulsive  contraction  which  is  known  to  affect  other 
involuntary  muscles.  More  frequently,  death  happens  at  a  later  period 
from  the  combined  effects  of  exhaustion  and  asphyxia.  The  records  of 
post-mortem  examinations  are  not  numerous ;  in  those  we  possess,  the 
principal  changes  have  been  an  anaemic  condition  of  the  brain,  with 
some  O3dematous  infiltration.  In  a  few  rare  cases  the  convulsions  have 
resulted  in  effusion  of  blood  into  the  ventricles,  or  at  the  base  of  the 
brain.  The  prognosis  as  regards  the  child  is  also  serious.  Out  of 
thirty-six  children,  Hall  Davis  found  twenty-six  born  alive,  ten  being 
stillborn.  There  is  good  reason  to  believe  that  the  convulsion  may 
attack  the  child  in  utero — of  this  several  examples  are  mentioned  by 
Cazeaux ;  or  it  may  be  subsequently  attacked  with  convulsions,  even 
when  apparently  healthy  at  birth. 

Pathology. — The  precise  pathology  of  eclampsia  cannot  be  con- 
sidered by  any  means  satisfactorily  settled.  When,  in  the  year  1843, 
Lever  first  showed  that  the  urine  in  patients  suffering  from  puerperal 
convulsions  was  generally  highly  charged  with  albumin — a  fact  which 
subsequent  experience  has  amply  confirmed — it  was  thought  that  a  key 
to  the  etiology  o'f  the  disease  had  been  found.  It  was  known  that 
chronic  forms  of  Bright's  disease  were  frequently  associated  with  reten- 
tion of  urinary  elements  in  the  blood,  and  not  rarely  accompanied  by 
convulsions.  The  natural  inference  was  drawn  that  the  convulsions  of 
eclampsia  were  also  due  to  toxaemia  resulting  from  the  retention  of 
urea  in  the  blood,  just  as  in  the  uraemia  of  chronic  Bright's  disease; 
and  this  viewT  was  adopted  and  supported  by  the  authority  of  Braun, 
Frerichs,  and  many  other  writers  of  eminence,  and  was  pretty  generally 
received  as  a  satisfactory  explanation  of  the  facts.  Frerichs  modified 
it  so  far  that  he  held  that  the  true  toxic  element  was  not  urea  as  such, 

i  The  Puerperal  Diseases,  p.  125.  a  Guy's  Hospital  Reports,  1870. 


PUERPERAL    ECLAMPSIA.  607 

but  carbonate  of  ammonia,  resulting  from  its  decomposition ;  and  ex- 
periments were  made  to  prove  that  the  injection  of  this  substance  into 
the  veins  of  the  lower  animals  produced  convulsions  of  precisely  the 
same  character  as  eclampsia.  Dr.  Hammond,1  of  Maryland,  subse- 
quently made  a  series  of  counter-experiments  which  were  held  as 
proving  that  there  was  no  reason  to  believe  that  urea  ever  did  become 
decomposed  in  the  blood  in  the  way  that  Frerichs  supposed,  or  that  the 
symptoms  of  uremia  were  ever  produced  in  this  way.  Others  have 
believed  that  the  poisonous  elements  retained  in  the  blood  are  not  urea 
or  the  products  of  its  decomposition,  but  other  extractive  matters 
which  have  escaped  detection.  As  time  elapsed,  evidence  accumulated 
to  show  that  the  relation  between  albujainuria  and  eclampsia  was  not 
so  universal  as  was  supposed,  or  at  least  that  some  other  factors  were 
necessary  to  explain  many  of  the  cases.  Numerous  cases  were  observed 
in  which  albumin  was  detected  in  large  quantities,  without  any  con- 
vulsion following,  and  that  not  only  in  women  who  had  been  subject 
to  Bright's  disease  before  conception,  but  also  when  the  albumin- 
uria  was  known  to  have  developed  during  pregnancy.  Thus  Imbert 
Goubeyre  found  that  out  of  164  cases  of  the  latter  kind,  95  had  no 
eclampsia ;  and  Blot,  out  of  41  cases,  found  that  34  were  delivered 
without  untoward  symptoms.  It  may  be  taken  as  proved,  therefore, 
that  albuminuria  is  by  no  means  necessarily  accompanied  by  eclampsia. 
Cases  were  also  observed  in  which  the  albumin  only  appeared  after  the 
convulsion ;  and  in  these  it  was  evident  that  the  retention  of  urinary 
elements  could  not  have  been  the  cause  of  the  attack ;  and  it  is  highly 
probable  that  in  them  the  albuminuria  was  produced  by  the  same  cause 
which  induced  the  convulsion.  Special  attention  has  been  called  to 
this  class  of  cases  by  Braxton  Hicks,2  who  has  recorded  a  considerable 
number  of  them.  He  says  that  the  nearly  simultaneous  appearance  of 
albumiuuria  and  convulsion — and  it  is  admitted  that  the  two  are  almost 
invariably  combined — must  then  be  explained  in  one  of  three  ways : 

1.  That  the  convulsions  are  the  cause  of  the  nephritis. 

2.  That  the  convulsions  and  the  nephritis  are  produced  by  the  same 
cause,  e.  g.,  some  detrimental  ingredient  circulating  in  the  blood,  irri- 
tating both  the  cerebro-spinal  system  and  other  organs  at  the  same 
time. 

3.  That  the  highly  congested  state  of  the  venous  system  induced  by 
the  spasm  of  the  glottis  in  eclampsia  is  able  to  produce  the  kidney 
complication. 

More  recently  Traube  and  Rosenstein  have  advanced  a  theory  of 
eclampsia  purporting  to  explain  these  anomalies.  They  refer  the 
occurrence  of  eclampsia  to  acute  cerebral  anaemia  resulting  from 
changes  in  the  blood  incident  to  pregnancy.  The  primary  factor  is 
the  hydrsemic  condition  of  the  blood,  which  is  an  ordinary  concomitant 
of  pregnancy,  and,  of  course,  when  there  is  also  albuminuria,  the 
\vatery  condition  of  the  blood  is  greatly  intensified  ;  hence  the  frequent 
association  of  the  two  states.  Accompanying  this  condition  of  the 
blood,  there  is  increased,  tension  of  the  arterial  system,  which  is 

1  Amer.  Journ.  of  Med.  Sciences,  1861.  a  Obst.  Trans.,  1867,  vol.  viii.  p.  323. 


608  THE    PUERPERAL    STATE. 

favored  by  the  hypertrophy  of  the  heart  which  is  known  to  be  a  nor- 
mal occurrence  in  pregnancy.  The  result  of  thes^e  combined  states  is 
a  temporary  hypersemia  of  the  brain,  which  is  rapidly  succeeded  by 
serous  eifusion  into  the  cerebral  tissues,  resulting  in  pressure  on  its 
minute  vessels  and  consequent  anaemia.  There  is  much  in  this  theory 
that  accords  with  the  most  recent  views  as  to  the  etiology  of  convulsive 
disease ;  as,  for  example,  the  researches  of  Kussmaul  and  Tenner,  who 
had  experimentally  proved  the  dependence  of  convulsions  on  cerebral 
ansemia,  and  of  Brown-Sequard,  who  showed  that  an  anaemic  condition 
of  the  nerve-centres  preceded  an  epileptic  attack.  It  explains  also 
very  satisfactorily  how  the  occurrence  of  labor  should  intensify  the 
convulsions,  since,  during  the  acme  of  the  pains,  the  tension  of  the 
cerebral  arterial  system  is  necessarily  greatly  increased.  There  are, 
howrever,  obvious  difficulties  against  its  general  acceptance.  For  ex- 
ample, it  does  not  satisfactorily  account  for  those  cases  which  are 
preceded  by  well-marked  precursory  symptom*,  and  in  which  an 
abundance  of  albumin  is  present  in  the  urine.  Here  the  premonitory 
signs  are  precisely  those  which  precede  the  development  of  uraemia  in 
chronic  Bright's  disease,  the  dependence  of  which  on  the  retention  in 
the  blood  of  urinary  elements  can  hardly  be  doubted.  Moreover,  it 
has  been  shown  by  Lohlein  and  others  that  on  post-mortem  examination 
the  brain  does  not,  as  a  rule,  exhibit  the  oedema,  anaemia,  and  flattened 
convolutions  which  this  theory  assumes. 

MacDonald1  has  published  an  interesting  paper  on  this  subject,  in 
which  he  describes  two  very  careful  post-mortem  examinations.  In 
these  he  found  extreme  anaemia  of  the  cerebro-spinal  centres,  with 
congestion  of  the  meninges,  but  no  evidence  of  oedema.  He  inclines 
to  the  belief  that  eclampsia  is  caused  by  irritation  of  the  vasomotor 
centre  in  consequence  of  an  anaemic  condition  of  the  blood  produced 
by  the  retention  in  it  of  excrementitious  matters  which  the  kidneys 
ought  to  have  removed,  this  over-stimulation  resulting  in  anaemia  of 
the  deeper-seated  nerve-centres  and  consequent  convulsion. 

Excitability  of.  the  Nervous  System  in  Puerperal  Women  as 
Predisposing-  to  Convulsions. — The  key  to  the  liability  of  the  puer- 
pera  to  convulsive  attacks  is  no  doubt  to  be  found  in  the  peculiarly 
excitable  condition  of  the  nervous  system  in  pregnancy — a  fact  which 
was  clearly  pointed  out  by  the  late  Dr.  Tyler  Smith  and  by  many 
other  writers.  Her  nervous  system  is,  in  this  respect,  not  unlike  that 
of  children,  in  whom  the  predominant  influence  and  great  excitability 
of  the  nervous  system  are  well-established  facts,  and  in  whom  precisely 
similar  convulsive  seizures  are  of  common  occurrence  on  the  applica- 
tion of  a  sufficiently  exciting  cause. 

Exciting'  Causes. — Admitting  this,  we  require  some  cause  to  set 
the  predisposed  nervous  system  into  morbid  action,  and  this  we  may 
have  either  in  the  toxaemic  or  in  an  extremely  watery  condition  of 
the  blood,  associated  with  albuminuria  ;  or  along  with  these,  or  some- 
times independently  of  them,  in  some  excitement,  such  as  strong  emo- 
tional disturbance.  It  is  highly  probable,  however,  that  extreme 

1  See  his  volume  of  collected  essays,  entitled  Heart  Disease  during  Pregnancy.    London,  1878. 


PUERPERAL    ECLAMPSIA.  609 

anaemia  is  one  of  the  actual  conditions  of  the  nerve-centres — a  fact  of 
much  practical  importance  in  reference  to  treatment. 

Treatment. — The  management  of  cases  in  which  the  occurrence  of 
suspicious  symptoms  has  led  to  the  detection  of  albuminuria  has 
already  been  fully  discussed  (p.  215).  We  shall  therefore,  here,  only 
consider  the  treatment  of  cases  in  which  convulsions  have  actually 
occurred. 

Until  quite  recently  venesection  was  regarded  as  the  sheet-anchor 
in  the  treatment,  and  blood  was  always  removed  copiously,  and,  there 
is  sufficient  reason  to  believe,  with  occasional  remarkable  benefit. 
Many  cases  are  recorded  in  which  a  patient,  in  apparently  profound 
coma,  rapidly  regained  her  consciousness  when  blood  was  extracted  in 
sufficient  quantity.  The  improvement,  however,  was  often  transient, 
the  convulsions  subsequently  recurring  with  increased  vigor.  There 
are  good  theoretical  grounds  for  believing  that  bloodletting  can  only 
be  of  merely  temporary  use,  and  may  even  increase  the  tendency  to 
convulsion.  These  are  so  well  put  by  Schroeder,  that  I  cannot  do 
better  than  quote  his  observations  on  this  point :  "  If,"  he  says,  "  the 
theory  of  Traube  and  Rosenstein  be  correct,  a  sudden  depletion  of  the 
vascular  system,  by  which  the  pressure  is  diminished,  must  stop  the 
attacks.  From  experience  it  is  known  that  after  venesection  the  quan- 
tity of  blood  soon  becomes  the  same  through  the  serum  taken  from  all 
the  tissues,  while  the  quality  is  greatly  deteriorated  by  the  abstraction 
of  blood.  A  short  time  after  venesection  we  shall  expect  to  find 
the  former  blood-pressure  in  the  arterial  system,  but  the  blood  far 
more  watery  than  previously.  From  this  theoretical  consideration, 
it  follows  that  abstraction  of  blood,  if  the  above-mentioned  conditions 
really  cause  convulsions,  must  be  attended  by  an  immediate  favorable 
result,  and,  under  certain  circumstances,  the  whole  disease  may  surely 
be  cut  short  by  it.  But,  if  all  other  conditions  remain  the  same,  the 
blood-pressure  will  after  some  time  again  reach  its  former  height. 
The  quality  of  blood  has  in  the  meantime  been  greatly  deteriorated, 
and  consequently  the  danger  of  the  disease  will  be  increased." 

These  views  sufficiently  well  explain  the  varying  opinions  held  with 
regard  to  this  remedy,  and  enable  us  to  understand  why,  while  the 
effects  of  venesection  have  been  so  lauded  by  certain  authors,  the  mor- 
tality has  admittedly  been  much  lessened  since  its  indiscriminate  use 
has  been  abandoned.  It  does  not  follow  because  a  remedy,  when 
carried  to  excess,  is  apt  to  be  hurtful  that  it  should  be  discarded 
altogether ;  and  I  have  no  doubt  that  in  properly  selected  cases  and 
judiciously  employed,  venesection  is  a  valuable  aid  in  the  treatment  of 
eclampsia,  and  that  it  is  specially  likely  to  be  useful  in  mitigating  the 
first  violence  of  the  attack  and  in  giving  time  for  other  remedies  to 
come  into  action.  Care  should,  however,  be  taken  to  select  the  cases  • 
proj)erly,  and  it  will  be  specially  indicated  when  there  is  marked 
evidence  of  great  cerebral  congestion  and  vascular  tension,  such  as  a 
livid  face,  a  full  bounding  pulse,  and  strong  pulsation  in  the  carotids. 
The  general  constitution  of  the  patient  may  also  serve  as  a  guide  in 
determining  its  use,  and  we  shall  be  the  more  disposed  to  resort  to  it 
if  the  patient  be  a  strong  and  healthy  woman ;  while  on  the  other 

39 


610  THE    PUERPERAL    STATE. 

hand,  if  she  be  feeble  and  weak,  we  may  wisely  discard  it  and  trust 
entirely  to  other  means.  In  any  case  it  must  be  looked  upon  as  a 
temporary  expedient  only,  useful,  in  warding  off  immediate  danger  to 
the  cerebral  tissues,  but  never  as  the  main  agent  in  treatment.  Nor 
can  it  be  permissible  to  bleed  in  the  heroic  manner  frequently  recom- 
mended. A  single  bleeding,  the  amount  regulated  by  the  effect 
produced,  is  all  that  is  ever  likely  to  be  of  service. 

As  a  temporary  expedient,  having  the  same  object  in  view,  com- 
pression of  the  carotids  during  the  paroxysms  is  worthy  of  trial.  This 
was  proposed  by  Trousseau  in  the  eclampsia  of  infants,  and  in  the 
single  case  of  eclampsia  in  which  I  have  tried  it,  it  seemed  decidedly 
beneficial.  It  is  simple,  and  it  offers  the  advantage  of  not  leading 
to  any  permanent  deterioration  of  the  blood,  as  in  venesection. 

As  a  subsidiary  means  of  diminishing  vascular  tension  the  admin- 
istration of  a  strong  purgative  is  desirable,  and  has  the  further  effect 
of  removing  any  irritant  matter  that  may  be  lodged  in  the  intestinal 
tract.  If  the  patient  be  conscious,  a  full  dose  of  the  compound  jalap 
powder  may  be  given,  or  a  few  grains  of  calomel  combined  with  jalap ; 
if  comatose  and  unable  to  swallow,  a  drop  of  croton  oil  or  a  quarter 
of  a  grain  of  elaterium  may  be  placed  on  the  back  of  the  tongue. 

The  great  indication  in  the  management  of  eclampsia  is  the  con- 
trolling of  convulsive  action  by  means  of  sedatives.  Foremost  amongst 
them  must  be  placed  the  inhalation  of  chloroform,  a  remedy  which  is 
frequently  remarkably  useful,  and  which  has  the  advantage  of  being 
applicable  at  all  stages  of  the  disease,  and  whether  the  patient  be 
comatose  or  not.  Theoretical  objections  have  been  raised  against  its 
employment,  as  being  likely  to  increase  cerebral  congestion  :  of  this 
there  is  no  satisfactory  proof;  on  the  contrary  there  is  reason  to  think 
that  chloroform  inhalation  has  rather  the  effect  of  lessening  arterial 
tension,  while  it  certainly  controls  the  violent  muscular  action  by 
which  the  hypersemia  is  so  much  increased.  Practically  no  one  who 
has  used  it  can  doubt  its  great  value  in  diminishing  the  force  and 
frequency  of  the  convulsive  paroxysms.  Statistically  its  usefulness  is 
shown  by  Charpentier  in  his  thesis  on  the  effects  of  various  methods 
of  treatment  in  eclampsia,  since  out  of  sixty-three  cases  in  which  it 
was  used,  in  forty-eight  it  had  the  effect  of  diminishing  or  arresting 
the  attacks,  one  only  proving  fatal.  The  mode  of  administration  has 
varied.  Some  have  given  it  almost  continuously,  keeping  the  patient 
in  a  more  or  less  profound  state  of  anaesthesia.  Others  have  contented 
themselves  with  carefully  watching  the  patient,  and  exhibiting  the 
chloroform  as  soon  as  there  were  any  indications  of  a  recurring 
paroxysm,  with  the  view  of  controlling  its  intensity.  The  latter  is 
the  plan  I  have  myself  adopted,  and  of  the  value  of  which  in  most 
cases  I  have  no  doubt.  Every  now  and  again  cases  will  occur  in 
which  chloroform  inhalation  is  insufficient  to  control  the  paroxysm,  or 
in  which,  from  the  very  cyanosed  state  of  the  patient,  its  administra- 
tion seems  contra-indicated.  Moreover,  it  is  advisable  to  have,  if 
}>u->ible,  some  remedy  more  continuous  in  its  action  and  requiring 
ess  constant  personal  supervision.  Latterly  the  internal  administra- 
tion of  chloral  has  been  recommended  for  this  purpose.  My  own 


PUERPERAL    ECLAMPSIA.  611 

experience  is  decidedly  in  its  favor,  and  I  have  used,  Avith,  as  I  believe, 
marked  advantage,  a  combination  of  chloral  with  bromide  of  potassium, 
in  the  proportion  of  twenty  grains  of  the  former  to  half  a  drachm  of 
the  latter,  repeated  at  intervals  of  from  four  to  six  hours.  If  the 
patient  be  unable  to  swallow,  the  chloral  may  be  given  in  an  enema 
or  hypodermically,  six  grains  being  diluted  in  5j  of  water,  and  injected 
under  the  skin.  The  remarkable  influence  of  bromide  of  potassium 
in  controlling  the  eclampsia  of  infants  would  seem  to  be  an  indication 
for  its  use  in  puerperal  cases.  Fordyce  Barker  was  opposed  to  the  use 
of  chloral,  which  he  thought  excited  instead  of  lessening  reflex  irrita- 
bility.1 Another  remedy,  not  entirely  free  from  theoretical  objections, 
but  strongly  recommended,  is  the  subcutaneous  injection  of  morphia, 
which  has  the  advantage  of  being  applicable  when  the  patient  is  quite 
unable  to  swallow.  It  may  be  given  in  doses  of  one-third  of  a  grain, 
repeated  in  a  few  hours,  so  as  to  keep  the  patient  well  under  its  influ- 
ence. It  is  to  be  remembered  that  the  object  is  to  control  muscular 
action,  so  as  to  prevent  as  much  as  possible  the  violent  convulsive 
paroxysm,  and,  therefore,  it  is  necessary  that  the  narcosis,  however  pro- 
duced, should  be  continuous.  It  is  rational,  therefore,  to  combine  the 
intermittent  action  of  chloroform  with  the  more  continuous  action  of, 
other  remedies,  so  that  the  former  should  supplement  the  latter  when 
insufficient.  Inhalation  of  the  nitrite  of  amyl  has  been  recommended 
on  physiological  grounds  as  likely  to  be  useful,  and  is  well  worthy  of  - 
trial ;  but  of  its  action  I  have,  as  yet,  no  personal  experience.  Several 
very  successful  cases  of  treatment  by  the  inhalation  of  oxygen  have 
been  recorded  by  Schmidt,  of  St.  Petersburg.2  Pilocarpine  has  recently 
been  tried,  in  the  hope  that  the  diaphoresis  and  salivation  it  produces 
might  diminish  arterial  tension  and  free  the  blood  of  toxic  matters. 
Braun3  administered  three  centigrammes  of  the  muriate  of  pilocarpine 
hypodermically,  and  reports  favorably  of  the  result ;  Fordyce  Barker,4 
however,  was  of  opinion  that  it  produced  so  much  depression  as  to  be 
dangerous. 

Other  remedies,  supposed  to  act  in  the  way  of  antidotes  to  ursemic 
poisoning,  have  been  advised,  such  as  acetic  or  benzoic  acid,  but  they 
are  far  too  uncertain  to  have  any  reliance  placed  on  them,  and  they 
distract  attention  from  more  useful  measures. 

Precautions  during  the  Paroxysm. — Precautions  are  necessary 
during  the  fits  to  prevent  the  patient  injuring  herself,  especially  to 
obviate  laceration  of  the  tongue  ;  the  latter  can  be  best  done  by  placing 
something  between  the  teeth  as  the  paroxysm  comes  on,  such  as  the 
handle  of  a  teaspoon  enveloped  in  several  folds  of  flannel. 

Obstetric  Management. — The  obstetric  management  of  eclampsia 
will  naturally  give  rise  to  much  anxiety,  and  on  this  point  there  has 
been  considerable  difference  of  opinion.  On  the  one  hand,  we  have 
practitioners  who  advise  the  immediate  emptying  of  the  uterus,  even 
when  labor  has  commenced ;  on  the  other,  those  who  would  leave  the 
labor  entirely  alone.  Thus  Gooch  said  :  "  Attend  to  the  convulsions, 

1  The  Puerperal  Diseases,  p.  120. 

«  London  Med.  Record,  1836,  vol.  xiv.  p.  75.    (Extr.  from  Russkaia  Meditz.,  1885,  No.  32,  p.  595.) 

»  Berl.  klin.  Wochenschr.,  June  16, 1879.  4  New  York  Med.  Record,  March  1, 1879. 


612  THE    PUERPERAL    STATE. 

and  leave  the  labor  to  take  care  of  itself;"  and  Schroeder  said :  "  Espe- 
cially no  kind  of  obstetric  manipulation  is  required  for  the  safety  of 
the  mother/'  but  he  admitted  that  it  is  sometimes  advisable  to  hasten 
the  labor  to  insure  the  safety  of  the  child. 

In  cases  in  which  the  convulsions  come  on  during  labor,  the  pains 
are  often  strong  and  regular,  the  labor  progresses  satisfactorily,  and 
no  interference  is  needful.  In  others  we  cannot  but  feel  that  empty- 
ing the  uterus  would  be  decidedly  beneficial.  We  have  to  reflect, 
however,  that  any  active  interference  might,  of  itself,  prove  very 
irritating  and  excite  fresh  attacks.  The  influence  of  uterine  irritation 
is  apparent  by  the  frequency  with  which  the  paroxysms  recur  with 
the  pains.  If,  therefore,  the  os  be  undilated  and  labor  have  not 
begun,  no  active  means  to  induce  it  should  be  adopted,  although  the 
membranes  may  be  ruptured  with  advantage,  since  that  procedure 
produces  no  irritation.  Forcible  dilatation  of  the  os,  and  especially 
turning,  are  strongly  contra-indicated. 

The  rule  laid  down  by  Tyler  Smith  seems  that  which  is  most 
advisable  to  follow — that  we  should  adopt  the  course  which  seems 
least  likely  to  prove  a  source  of  irritation  to  the  mother.  Thus,  if 
the  fits  seem  evidently  induced  and  kept  up  by  the  pressure  of  the 
foetus,  and  the  head  be  within  reach,  the  forceps  may  be  resorted  to. 
But  if,  on  the  other  hand,  there  be  reason  to  think  that  the  operation 
•necessary  to  complete  delivery  is  likely  per  se  to  prove  a  greater 
source  of  irritation  than  leaving  the  case  to  Nature,  then  we  should 
not  interfere. 

[If  called  to  a  case  of  convulsions  followed  by  coma  in  a  primipara 
near  term,  but  not  in  labor,  draw  off  a  little  urine  and  examine  it,  as 
the  patient  may  be  far  advanced  in  Bright's  disease  and  the  coma 
purely  ura?mic.  In  such  a  case  little  can  be  gained  by  bringing  on 
labor  and  delivering  the  foetus. 

Eclampsia  is  sometimes  purely  reflex,  and  not  at  all  dangerous, 
although  it  may  be  alarming.  The  convulsive  movements  may  arise 
from  nerve-disturbance  due  to  the  foetal  head  distending  the  cervix  in 
the  last  stage  of  dilatation  in  primipara?.  When  the  head  begins  to 
distend  the  perineum  the  convulsive  seizure  often  ceases.  Such  patients 
are  safer  without  the  forceps. — ED.] 


CHAPTER    IY. 

PUERPERAL  INSANITY. 

Classification. — Under  the  head  of  "  Puerperal  Mania,"  writers  on 
obstetrics  have  indiscriminately  classed  all  cases  of  mental  disease 
connected  with  pregnancy  and  parturition.  The  result  has  been  unfor- 
tunate, for  the  distinction  between  the  various  types  of  mental  disorder 


PUERPERAL    INSANITY.  613 

has,  in  consequence,  been  very  generally  lost  sight  of.  But  little  study 
of  the  subject  suffices  to  show  that  the  term  puerperal  mania  is  wrong 
in  more  ways  than  one,  for  we  find  that  a  large  number  of  cases  are 
not  cases  of  "  mania  "  at  all,  but  of  melancholia ;  while  a  considerable 
number  are  not,  strictly  speaking,  "  puerperal,"  as  they  either  come 
on  during  pregnancy,  or  long  after  the  immediate  risks  of  the  puerperal 
period  are  over,  being  in  the  latter  case  associated  with  anaemia  pro- 
duced by  over-lactation.  For  the  sake  of  brevity  the  generic  term, 
"  puerperal  insanity,"  may  be  employed  to  cover  all  cases  of  mental 
disorders  connected  with  gestation,  which  may  be  further  conveniently 
subdivided  into  three  classes,  each  having  its  special  characteristics, 
viz. : 

I.  The  insanity  of  pregnancy. 
II.  Puerperal  insanity,  properly  so  called  ;  that  is,  insanity  coming 

on  within  a  limited  period  after  delivery. 
III.   The  insanity  of  lactation. 

This  division  is  a  strictly  natural  one,  and  includes  all  the  cases 
likely  to  come  under  observation.  The  relative  proportion  these 
classes  bear  to  each  other  can  only  be  determined  by  accurate  statistical 
observations  on  a  large  scale,  but  these  materials  we  do  not  possess. 
The  returns  from  large  asylums  are  obviously  open  to  objection,  for 
only  the  worst  and  most  confirmed  cases  find  their  way  into  these 
institutions,  while  by  far  the  greater  proportion,  both  before  and  after 
labor,  are  treated  in  their  own  homes. 

Proportion  of  these  forms  of  insanity.  Taking  such  returns 
as  only  approximate,  we  find  from  Dr.  Batty  Tuke1  that  in  the  Edin- 
burgh Asylum,  out  of  155  cases  of  puerperal  insanity,  28  occurred 
before  delivery,  73  during  the  puerperal  period,  and  54  during  lacta- 
tion. The  relative  proportions  of  each  per  hundred  are  as  follows  : 

Insanity  of  pregnancy       .  18.06  per  cent. 

Puerperal  insanity 47.09        " 

Insanity  of  lactation 34.83        " 

Marc62  collects  together  several  series  of  cases  from  various  authorities, 
amounting  to  310  in  all,  and  the  results  are  not  very  different  from 
those  of  the  Edinburgh  Asylum,  except  in  the  relatively  smaller 
number  of  cases  occurring  before  delivery.  The  percentage  is  calcu- 
lated from  his  figures : 

Insanity  of  pregnancy 8.06  per  cent. 

Puerperal  insanity 58.06        " 

Insanity  of  lactation  ...  30.30 

As  each  of  these  classes  differs  in  various  important  respects  from  the 
others,  it  will  be  better  to  consider  each  separately. 

The  Insanity  of  Pregnancy  is,  without  doubt,  the  least  common 
of  the  three  forms.  The  intense  mental  depression  which  in  many 
women  accompanies  pregnancy,  and  causes  the  patient  to  take  a 
despondent  view  of  her  condition,  and  to  look  forward  to  the  result 
of  her  labor  with  the  most  gloomy  apprehension,  seems  to  be  often 

1  Edin.  Med.  Journ.,  vol.  x.  <       J  TraiW  de  la  Folie  des  Femmes  enceintes. 


614  THE    PUERPERAL    STATE. 

only  a  lesser  degree  of  the  actual  mental  derangement  which  is  occa- 
sionally met  with.  The  relation  between  the  two  states  is  further 
borne  out  by  the  fact  that  a  large  majority  of  cases  of  insanity  during 
pregnancy  are  well-marked  types  of  melancholia ;  out  of  28  cases 
recorded  by  Tuke,  15  were  examples  of  pure  melancholia,  and  5  of 
dementia  with  melancholia.  In  many  of  these  the  attack  could  be 
traced  as  developing  itself  out  of  the  ordinary  hypochondriasis  of 
pregnancy.  In  others  the  symptoms  came  on  "at  a  later  period  of 
pregnancy,  the  earlier  months  of  which  had  not  been  marked  by  any 
unusual  lowness  of  spirits.  The  age  of  the  patient  seems  to  have 
some  influence,  the  proportion  of  cases  between  thirty  and  forty  years 
of  age  being  much  larger  than  in  younger  women.  A  larger  propor- 
tion of  cases  occurs  in  primiparae  than  in  multipart,  a  fact  that  no 
doubt  depends  on  the  greater  dread  and  apprehension  experienced  by 
women  who  are  pregnant  for  the  first  time,  especially  if  not  very 
young.  Hereditary  disposition  plays  an  important  part,  as  in  all 
forms  of  puerperal  insanity.  It  is  not  always  easy  to  ascertain  the 
fact  of  an  hereditary  taint,  since  it  is  often  studiously  concealed  by 
the  friends.  Tuke,  however,  found  distinct  evidence  of  it  in  no  less 
than  12  out  of  28  cases.  Fiirstner1  believes  that  other  neuroses  have 
an  important  influence  in  the  production  of  the  disease.  Out  of  32 
cases  he  found  direct  hereditary  taint  in  9,  but  in  11  more  there  was 
a  family  history  of  epilepsy,  drunkenness,  or  hysteria. 

Period  of  pregnancy  at  which  it  occurs.  The  period  of  preg- 
nancy at  which  mental  derangement  most  commonly  shows  itself 
varies.  Most  generally,  perhaps,  it  is  at  the  end  of  the  third  or  the 
beginning  of  the  fourth  month.  It  may,  however,  begin  with  con- 
ception, and  even  return  with  every  impregnation.  Montgomery 
relates  an  instance  in  which  it  recurred  in  three  successive  pregnan- 
cies. Marce  distinguishes  between  true  insanity  coming  on  during 
pregnancy  and  aggravated  hypochondriasis,  by  the  fact  that  the  latter 
usually  lessens  after  the  third  month,  while  the  former  most  com- 
monly begins  after  that  date.  It  is  unquestionable  that  in  many  cases 
no  such  distinction  can  be  made,  and  that  the  two  are  often  very  inti- 
mately associated. 

The  form  of  insanity  does  not  differ  from  ordinary  melancholia. 
The  suicidal  tendency  is  generally  very  strongly  developed.  Should 
the  mental  disorder  continue  after  delivery,  the  patient  may  very 
probably  experience  a  strong  impulse  to  kill  her  child.  Moral  per- 
versions have  not  been  uncommonly  observed.  Tuke  especially  men- 
tions a  tendency  to  dipsomania  in  the  early  months,  even  in  women 
who  have  not  shown  any  disposition  to  excess  at  other  times.  He 
suggests  that  this  may  be  an  exaggeration  of  the  depraved  appetite  or 
morbid  craving  so  commonly  observed  in  pregnant  women,  just  as 
melancholia  may  be  a  further  development  of  lowness  of  spirits. 
Laycock  mentions  a  disposition  to  "kleptomania"  as  very  character- 
istic of  the  disease.  Casper2  relates  a  curious  case  where  this  occurred 
in  a  pregnant  lady  of  rank,  and  the  influence  of  pregnancy  in  devel- 

i  Archiv  far  Psychiatric,  Band  v.  Heft  2. 

8  Casper's  Forensic  Medicine,  New  Syd.  Soc.,  vol.  iv.  p.  308. 


PUERPERAL    INSANITY.  615 

oping  an  irresistible  tendency  was  pleaded  in  a  criminal  trial  in  which 
one  of  her  petty  thefts  had  involved  her. 

The  prognosis  may  be  said  to  be,  on  the  whole,  favorable.  Out  of 
Dr.  Tuke's  twenty-eight  cases,  nineteen  recovered  within  six  months. 
There  is  little  hope  of  a  cure  until  after  the  termination  of  the  preg- 
nancy, as  out  of  nineteen  cases  recorded  by  Marce,  in  only  two  did 
the  insanity  disappear  before  delivery. 

Transient  Mania  during-  Delivery. — There  is  a  peculiar  form  of 
mental  derangement  sometimes  observed  during  labor,  which  is  by 
some  talked  of  as  a  temporary  insanity.  It  may,  perhaps,  be  more 
accurately  described  as  a  kind  of  acute  delirium,  produced,  in  the 
latter  stage  of  labor,  by  the  intensity  of  the  suffering  caused  by  the 
pains.  According  to  Montgomery,  it  is  most  apt  to  occur  as  the  head 
is  passing  through  the  os  uteri,  or  at  a  later  period,  during  the  expul- 
sion of  the  child.  It  may  consist  of  merely  a  loss  of  control  over  the 
mind,  during  which  the  patient,  unless  carefully  watched,  might,  in  her 
agony,  seriously  injure  herself  or  her  child.  Sometimes  it  produces 
actual  hallucination,  as  in  the  case  described  by  Tarnier,  in  which  the 
patient  fancied  she  saw  a  spectre  standing  at  the  foot  of  her  bed, 
which  she  made  violent  effort  to  drive  away.  This  kind  of  mania,  if 
it  may  be  so  called,  is  merely  transitory  in  its  character,  and  disap- 
pears as  soon  as  the  labor  is  over.  From  a  medico-legal  point  of  view 
it  may  be  of  importance,  as  it  has  been  held  by  some  that  in  certain 
cases  of  infanticide  the  mother  has  destroyed  the  child  when  in  this 
state  of  transient  frenzy,  and  when  she  was  irresponsible  for  her  acts. 
In  the  treatment  of  this  variety  of  delirium  we  must,  of  course,  try 
to  lessen  the  intensity  of  the  suffering,  and  it  is  in  such  cases  that 
chloroform  will  find  one  of  its  most  valuable  applications. 

True  Puerperal  Insanity  has  always  attracted  much  attention  from 
obstetricians,  often  to  the  exclusion  of  other  forms  of  mental  disturb- 
ance connected  with  the  puerperal  state.  We  may  define  it  to  be  that 
form  of  insanity  which  comes  on  within  a  limited  period  after  delivery, 
and  which  is  probably  intimately  connected  with  that  process.  Out 
of  seventy-three  examples  of  the  disease  tabulated  by  Dr.  Tuke,  only 
two  came  on  later  than  a  month  after  delivery,  and  in  these  there  were 
other  causes  present,  which  might  possibly  remove  them  from  this 
class. 

Although  a  large  number  of  these  cases  assume  the  character  of 
acute  mania,  that  is  by  no  means  the  only  kind  of  insanity  which  is 
observed,  a  not  inconsiderable  number  being  well-marked  examples  of 
melancholia.  The  distinction  between  them  was  long  ago  pointed  out 
by  Gooch,  whose  admirable  monograph  on  the  disease  contains  one  ot 
the  most  graphic  and  accurate  accounts  of  puerperal  insanity  that  has 
yet  been  written. 

There  are  also  some  peculiarities  as  to  the  period  at  which  these 
varieties  of  insanity  show  themselves,  which,  taken  in  connection  with 
certain  facts  in  their  etiology,  may  eventually  justify  us  in  drawing  a 
stronger  line  of  demarcation  between  them  than  has  been  usual.  It 
appears  that  cases  of  acute  mania  are  apt  to  come  on  at  a  period  much 
nearer  delivery  than  melancholia.  Thus  Tuke  found  that  all  the 


616  THE    PUERPERAL    STATE. 

cases  of  mania  came  on  within  sixteen  days  after  delivery,  and  that  all 
cases  of  melanchola  developed  themselves  after  that  period.  We 
shall  presently  see  that  one  of  the  most  recent  theories  as  to  the  cause 
of  the  disease  attributes  it  to  some  morbid  condition  of  the  blood. 
Should  further  investigation  confirm  this  supposition,  inasmuch  as 
septic  conditions  of  the  blood  are  most  likely  to  occur  a  short  time 
after  labor,  it  would  not  be  an  improbable  hypothesis  that  cases  of 
acute  mania,  occurring  within  a  short  time  after  labor,  may  depend  on 
such  septic  causes,  while  melancholia  is  more  likely  to  arise  from 
general  conditions  favoring  the  development  of  mental  disease.  This 
must,  however,  be  regarded  as  a  mere  speculation,  requiring  further 
investigation. 

Causes. — Hereditary  predisposition  is  very  frequently  met  with, 
and  a  careful  inquiry  into  the  patient's  history  will  generally  show 
that  other  members  of  the  family  have  suffered  from  mental  derange- 
ment. Reid  found  that  out  of  1 1 1  cases  in  Bethlehem  Hospital,  there 
was  clear  evidence  of  hereditary  taint  in  45.  Tuke  made  the  same 
observation  in  22  out  of  his  73  cases ;  and,  indeed,  it  is  pretty  gen- 
erally admitted  by  all  alienist  physicians  that  hereditary  tendencies 
form  one  of  the  strongest  predisposing  causes  of  mental  disturbance 
in  the  puerperal  state.  In  a  large  proportion  of  cases  circumstances 
producing  debility  and  exhaustion,  or  mental  depression,  have  pre- 
ceded the  attack.  Thus  it  is  often  found  that  patients  attacked  with 
it  have  had  post-partum  hemorrhage  or  have  suffered  from  some  other 
conditions  producing  exhaustion,  such  as  severe  and  complicated  labor; 
or  they  may  have  been  weakened  by  over-frequent  pregnancies,  or  by 
lactation  during  the  early  mouths  of  pregnancy.  Indeed,  anaemia  is 
always  well  marked  in  this  disease.  Mental  conditions  also  are  fre- 
quently traceable  in  connection  with  its  production.  Morbid  dread 
during  pregnancy,  insufficient  to  produce  insanity  before  delivery, 
may  develop  into  mental  derangement  after  it.  Shame  and  fear  of 
exposure  in  unmarried  women  not  unfrequently  lead  to  it,  as  is  evi- 
denced by  the  fact  that  out  of  2281  cases  gathered  from  the  reports 
of  various  asylums,  above  64  per  cent,  were  unmarried.1  Sudden 
moral  shocks  or  vivid  mental  impressions  may  be  the  determining 
cause  in  predisposed  persons.  Gooch  narrated  an  example  of  this  in 
a  lady  who  was  attacked  immediately  after  a  fright  produced  by  a  fire 
close  to  her  house,  the  hallucinations  in  this  case  being  all  connected 
with  light;  and  Tyler  Smith  that  of  another  whose  illness  dated  from 
the  sudden  death  of  a  relative.  The  age  of  the  patient  has  some 
influence,  and  there  seems  to  be  a  decidedly  greater  liability  at 
advanced  ages,  especially  when  such  women  are  pregnant  for  the  first 
time. 

The  possibility  of  the  acute  form  of  puerperal  insanity  coming  on 
shortly  after  delivery  being  dependent  on  some  form  of  septicaemia,  is 
one  which  deserves  careful  consideration.  The  idea  originated  with 
Sir  James  Simpson,  who  found  albumin  in  the  urine  of  four  patients. 
He  suggested  that  this  might  probably  indicate  the  presence  in  the 

1  Journ.  of  Mental  Science,  1870-71,  p.  159. 


PUERPERAL    INSANITY.  617 

blood  of  certain  urinary  constituents  which  might  have  determined 
the  attack  much  in  the  same  way  as  in  eclampsia.  Dr.  Donkin  sub- 
sequently wrote  an  important  paper,1  in  which  he  warmly  supported 
this  theory,  and  arrived  at  the  conclusion  "that  the  acute  dangerous 
«lass  of  cases  are  examples  of  ursemic  blood-poisoning,  of  which  the 
mania,  rapid  pulse,  and  other  constitutional  symptoms  are  merely  the 
phenomena;"  and  that  the  aifection,  therefore,  ought  to  be  termed 
urremic  or  renal  puerperal  mania,  in  contradistinction  to  the  other 
form  of  disease.  He  also  suggests  that  the  immediate  poison  may 
be  carbonate  of  ammonia,  resulting  from  the  decomposition  of  urea 
retained  in  the  blood.  It  will  be  observed,  therefore,  that  the  patho- 
logical condition  producing  puerperal  mania  would,  supposing  this 
theory  to  be  correct,  be  precisely  the  same  as  that  which  at  other 
times  is  supposed  to  give  rise  to  puerperal  eclampsia.  There  can  be 
no  doubt  that  the  patient,  immediately  after  delivery,  is  in  a  condition 
rendering  her  peculiarly  liable  to  various  forms  of  septic  disease;  and 
it  must  be  admitted  that  there  is  no  inherent  improbability  in  the  sup- 
position that  some  morbid  material  circulating  in  the  blood  may  be 
the  effective  cause  of  the  attack  in  a  person  otherwise  predisposed  to 
it.  It  is  also  certain,  as  I  have  already  pointed  out,  that  there  are 
two  distinct  classes  of  cases,  differing  according  to  the  period  after 
delivery  at  which  the  attack  comes  on.  Whether  this  difference 
depends  on  the  presence  in  the  blood  of  some  septic  matter — especially 
urinary  excreta — is  a  question  which  our  knowledge  by  no  means 
justifies  us  in  answering;  it  is,  however,  one  which  well  merits  further 
careful  study. 

It  is  only  fair  to  point  out  some  difficulties  which  appear  to  militate 
against  the  view  which  Dr.  Donkiu  maintains.  In  the  first  place,  the 
albuminuria  is  merely  transient,  while  its  supposed  effects  last  for 
weeks  or  months.  Sir  James  Simpson  said,  with  regard  to  his  cases : 
"  I  have  seen  all  traces  of  albuminuria  in  puerperal  insanity  disappear 
from  the  urine  within  fifty  hours  of  the  access  of  the  malady.  The 
general  rapidity  of  its  disappearance  is,  perhaps,  the  principal  or, 
indeed,  the  only  reason  why  this  complication  has  escaped  the  notice 
of  those  physicians  among  us  who  devote  themselves  with  such  ardor 
and  zeal  to  the  treatment  of  insanity  in  our  public  asylums."  This 
apparent  anomaly  Simpson  attempted  to  explain  by  the  hypothesis 
that,  when  once  the  uraemic  poisoning  has  done  its  work  and  set  the 
disease  in  progress,  the  mania  progresses  of  itself.  This,  however,  is 
pure  speculation ;  and,  in  the  supposed  analogous  case  of  eclampsia, 
the  albumiuuria  certainly  lasts  as  long  as  its  effects.  It  is  not  easy  to 
understand,  also,  why  ursemic  poisoning  should  in  one  case  give  rise 
to  insanity  and  in  another  to  convulsions.  For  all  we  know  to  the 
contrary,  transient  albuminuria  may  be  much  more  common  after 
delivery  than  has  been  generally  supposed,  and  further  investigation  on 
this  point  is  required.  Albumin  is  by  no  means  unfrequently  observed 
in  the  urine  for  a  short  time  in  various  conditions  of  the  body,  with- 
out any  serious  consequences,  as,  for  example,  after  bathing ;  and  we 

1  Edin.  Med.  Journ.,  vol.  vii. 


618  THE    PUERPERAL    STATE. 

may  too  readily  draw  an  unjustifiable  conclusion  from  its  detection  in 
a  few  cases  of  mania.  There  are,  however,  many  other  kinds  of  blood- 
poisoning  besides  uraemia  which  may  have  an  influence  in  the  produc- 
tion of  the  disease,  and  it  is  to  be  hoped  that  future  observations  may 
enable  us  to  speak  with  more  certainty  on  this  point. 

The  prognosis  of  puerperal  insanity  is  a  point  which  will  always 
deeply  interest  those  who  have  to  deal  with  so  distressing  a  malady. 
It  may  resolve  itself  into  a  consideration  of  the  immediate  risk  to  life 
and  of  the  chances  of  ultimate  restoration  of  the  mental  faculties.  It 
is  an  old  aphorism  of  Gooch's,  and  one  the  correctness  of  which  is  jus- 
tified by  modern  experience,  that  "  mania  is  more  dangerous  to  life, 
melancholia  to  reason."  It  has  very  generally  been  supposed  that  the 
immediate  risk  to  life  in  puerperal  mania  is  not  great,  and  on  the  whole 
this  may  be  taken  as  correct.  Tuke  found  that  death  took  place,  from 
all  causes,  in  10.9  per  cent,  of  the  cases  under  observation ;  these,  how- 
ever, were  all  women  who  had  been  admitted  into  asylums  and  in 
whom  the  attack  may  be  assumed  to  have  been  exceptionally  severe. 
Great  stress  was  laid  by  Hunter  and  Gooch  on  extreme  rapidity  of  the 
pulse  as  indicating  a  fatal  tendency.  There  can  be  no  doubt  that  it  is 
a  symptom  of  great  gravity,  but  by  no  means  one  which  need  lead  us 
to  despair  of  our  patient's  recovery.  The  most  dangerous  class  of  cases 
are  those  attended  with  some  inflammatory  complication  ;  and  if  there 
be  marked  elevation  of  temperature,  indicating  the  presence  of  some 
such  concomitant  state,  our  prognosis  must  be  more  grave  than  when 
there  is  mere  excitement  of  the  circulation. 

Post-mortem  signs.  There  are  no  marked  post-mortem  signs 
found  in  fatal  cases  to  guide  us  in  forming  an  opinion  as  to  the  nature 
of  the  disease.  "No  constant  morbid  changes,"  says  Tyler  Smith,  "are 
found  within  the  head,  and  most  frequently  the  only  condition  found 
in  the  brain  is  that  of  unusual  paleness  and  exsanguinity.  Many 
pathologists  have  also  remarked  upon  the  extremely  empty  condition 
of  the  bloodvessels,  particularly  the  veins. 

The  duration  of  the  disease  varies  considerably.  Generally  speak- 
ing, cases  of  mania  do  not  last  so  long  as  melancholia,  and  recovery 
takes  place  within  a  period  of  three  months,  often  earlier.  Very  few 
of  the  cases  admitted  into  the  Edinburgh  Asylum  remained  there  more 
than  six  months,  and  after  that  time  the  chances  of  ultimate  recovery 
greatly  lessened.  When  the  patient  gets  well  it  often  happens  that  her 
recollection  of  the  events  occurring  during  her  illness  is  lost ;  at  other 
times  the  delusions  from  which  she  suffered  remain,  as,  for  example, 
in  a  case  which  was  under  my  care,  in  which  the  personal  antipathies 
which  the  patient  formed  when  insane  became  permanently  established. 

Insanity  of  Lactation. — Fifty-four  out  of  the  155  cases  collected 
by  Dr.  Tuke  were  examples  of  the  insanity  of  lactation,  which  would 
appear,  therefore,  to  be  nearly  twice  as  common  as  that  of  pregnancy, 
but  considerably  less  so  than  the  true  puerperal  form.  Its  dependence 
on  causes  producing  ansemia  and  exhaustion  is  obvious  and  well 
marked.  In  the  large  majority  of  cases  it  occurs  in  multipart  who 
have  been  debilitated  by  frequent  pregnancies  and  by  length  of  nurs- 
ing. When  occurring  in  primiparse  it  is  generally  in  wromen  who 


PUERPERAL    INSANITY.  619 

have  suffered  from  post-partum  hemorrhage  or  other  causes  of  exhaus- 
tion, or  whose  constitution  was  such  as  should  have  contra-indicated 
any  attempt  at  lactation.  The  "bruit  de  diable"  is  almost  invariably 
present  in  the  veins  of  the  neck,  indicating  the  impoverished  condition 
of  the  blood. 

The  type  is  far  more  frequently  melancholic  than  maniacal,  and 
when  the  latter  form  occurs,  the  attack  is  much  more  transient  than  in 
true  puerperal  insanity.  The  danger  to  life  is  not  great,  especially  if 
the  cause  producing  debility  be  recgnized  and  at  once  removed. 

There  seems,  however,  to  be  more  risk  of  the  insanity  becoming 
permanent  than  in  the  other  forms.  In  twelve  out  of  Dr.  Tuke's  cases 
the  melancholia  degenerated  into  dementia  and  the  patients  became 
hopelessly  insane. 

Symptoms. — The  symptoms  of  these  various  forms  of  insanity  are 
practically  the  same  as  in  the  non-pregnant  state. 

Generally  in  cases  of  mania  there  is  more  or  less  premonitory  indi- 
cation of  mental  disturbance,  which  may  pass  unperceived.  The  attack 
is  often  preceded  by  restlessness  and  loss  of  sleep,  the  latter  being  a 
very  common  and  well-marked  symptom ;  or  if  the  patient  does  sleep, 
her  rest  is  broken  and  disturbed  by  dreams.  Causeless  dislikes  to 
those  around  her  are  often  observed ;  the  nurse,  the  husband,  the 
doctor,  or  the  child,  becomes  the  object  of  suspicion,  and  unless  proper 
care  be  taken  the  child  may  be  seriously  injured.  As  the  disease 
advances  the  patient  becomes  incoherent  and  rambling  in  her  talk, 
and,  in  a  fully  developed  case,  she  is  incessantly  pouring  forth  an  un- 
connected jumble  of  sentences,  out  of  which  no  meaning  can  be  made. 
Often  some  prevalent  idea  which  is  dwelling  in  the  patient's  mind  can 
be  traced  running  through  her  ravings,  and  it  has  been  noticed  that 
this  is  frequently  of  a  sexual  character,  causing  women  of  unblemished 
reputation  to  use  obscene  and  disgusting  language,  which  it  is  difficult 
to  understand  their  even  having  heard.  The  tendency  of  such  patients 
to  make  accusations  impugning  their  own  chastity  was  specially  insisted 
on  by  many  eminent  authorities  in  a  recent  celebrated  trial,  when  Sir 
James  Simpson  stated  that  in  his  experience  "  the  organ  diseased  gave 
a  type  to  the  insanity,  so  that  with  women  suffering  with  affections  of 
the  genital  organs  the  delusions  would  be  more  likely  to  be  connected 
with  sexual  matters."  Religious  delusions — as  a  fear  of  eternal  damna- 
tion, or  of  having  committed  some  unpardonable  sin — are  of  frequent 
occurrence,  but  perhaps  more  often  in  cases  which  are  tending  to  the 
melancholic  type.  There  is  generally  intolerable  restlessness,  and  the 
patient's  whole  manner  and  appearance  are  those  of  excessive  excite- 
ment. She  may  refuse  to  remain  in  bed,  may  tear  off  her  clothes,  or 
attempt  to  injure  herself.  The  suicidal  tendency  is  often  very  marked. 
In  one  case  under  my  care  the  patient  made  incessant  efforts  to  destroy 
herself,  which  wrere  only  frustrated  by  the  most  careful  watching ;  she 
endeavored  to  strangle  herself  with  the  bedclothes,  to  swallow  any 
article  she  could  lay  hold  of,  and  even  to  gouge  out  her  own  eyes. 
Food  is  generally  persistently  refused,  and  the  utmost  coaxing  may 
fail  in  inducing  the  patient  to  take  nourishment.  The  pulse  is  rapid 
and  small,  and  the  more  violent  the  excitement  and  furious  the 


620  THE    PUERPERAL    STATE. 

delirium,  the  more  excited  is  the  circulation.  The  tongue  is  coated 
and  furred,  the  bowels  constipated  and  disorded,  and  the  feces,  as  well 
as  the  urine,  are  frequently  passed  involuntarily.  The  urine  is  scanty 
and  high-colored,  and  after  the  disease  has  lasted  for  some  time  it 
becomes  loaded  with  phosphates.  The  lochia  and  the  secretion  of  milk 
generally  become  arrested  at  the  commencement  of  the  disease.  The 
waste  of  tissue,  from  the  incessant  restlessness  and  movement  of  the 
patient,  is  very  great ;  and  if  the  disease  continues  for  some  time  she 
tails  into  a  condition,  of  marasmus,  which  may  be  so  excessive  that 
she  becomes  wasted  to  a  shadow  of  her  former  size. 

When  the  insanity  assumes  the  form  of  melancholia,  its  advent  is 
more  gradual.  It  may  commence  with  depression  of  spirits,  without 
any  adequate  cause,  associated  with  insomnia,  disturbed  digestion,  head- 
ache, and  other  indications  of  bodily  derangement.  Such  symptoms 
showing  themselves  in  women  who  have  been  nursing  for  a  length  of 
time,  or  in  whom  any  other  evident  cause  of  exhaustion  exists,  should 
never  pass  unnoticed.  Soon  the  signs  of  mental  depression  increase 
and  positive  delusions  show  themselves.  These  may  vary  much  in 
their  amount,  but  they  are  all  more  or  less  of  the  same  type,  and  very 
often  of  a  religious  character.  The  amount  of  constitutional  disturb- 
ance varies  much.  In  some  cases  which  approach  in  character  those 
of  mania,  there  is  considerable  excitement,  rapid  pulse,  furred  tongue, 
and  restlessness.  Probably  cases  of  acute  melancholia,  coming  on 
during  the  puerperal  state,  most  often  assume  this  form.  In  others, 
again,  there  is  less  of  these  general  symptoms,  the  patients  are  pro- 
foundly dejected,  and  sit  for  hours  without  speaking  or  moving,  but 
there  is  not  much  excitement,  and  this  is  the  form  most  generally 
characterizing  the  insanity  of  lactation.  In  all  cases  there  is  a  marked 
disinclination  to  food.  There  is  also,  almost  invariably,  a  disposition 
to  suicide ;  and  it  should  never  be  forgotten  in  melancholic  cases  that 
this  may  develop  itself  in  an  instant,  and  that  a  moment's  carelessness 
on  the  part  of  the  attendants  may  lead  to  disastrous  residts. 

Treatment. — Bearing  in  mind  what  has  been  said  of  the  essential 
character  of  puerperal  insanity,  it  is  obvious  that  the  course  of  treat- 
ment must  be  mainly  directed  to  maintain  the  strength  of  the  patient, 
so  as  to  enable  her  to  pass  through  the  disease  without  fatal  exhaustion 
of  the  vital  powers,  while  we  endeavor  at  the  same  time  to  calm  the 
excitement  and  give  rest  to  the  disturbed  brain.  Any  over-active 
measures — for  example,  bleeding,  blistering  the  shaven  scalp,  and  the 
like — are  distinctly  contra-indicated. 

There  is  a  general  agreement  on  the  part  of  alienist  physicians  that 
in  cases  of  acute  mania  the  two  things  most  needed  are  a  sufficient 
quantity  of  suitable  food  and  sleep. 

Every  endeavor  should  be  made  to  induce  the  patient  to  take  plenty 
of  nourishment  to  remedy  the  defects  of  the  excessive  waste  of  tissue 
and  support  her  strength  until  the  disease  abates.  Dr.  Blandford,  who 
has  especially  insisted  on  the  importance  of  this,  says  :l  "  Xow  with 
regard  to  the  food,  skilful  attendants  will  coax  a  patient  into  taking  a 

'  Blandford  :  Insanity  and  its  Treatment. 


PUERPERAL    INSANITY.  621 

large  quantity,  and  we  can  hardly  give  too  much.  Messes  of  minced 
meat  with  potato  and  greens,  diluted  with  beef-tea,  bread  and  milk, 
rum  and  milk,  arrowroot,  and  so  on,  may  be  got  down.  Never  give 
mere  liquids  as  long  as  you  can  get  down  solids.  As  the  malady 
progresses,  the  tongue  and  mouth  may  become  so  dry  and  foul  that 
nothing  but  liquids  can  be  swallowed  ;  but,  reserving  our  beef-tea  and 
brandy,  let  us  give  plenty  of  solid  food  while  we  can." 

The  patient  may  in  mania,  as  well  as  in  melancholia,  perhaps  even 
more  in  the  latter,  obstinately  refuse  to  take  nourishment  at  all,  and 
we  may  be  compelled  to  use  force.  Various  contrivances  have  been 
employed  for  this  purpose.  One  of  the  simplest  is  introducing  a 
dessertspoon  forcibly  between  the  teeth,  the  patient  being  controlled 
by  an  adequate  number  of  attendants,  and  slowly  injecting  into  the 
mouth  suitable  nourishment  by  an  India-rubber  bottle  with  an  ivory 
nozzle,  such  as  is  sold  by  all  chemists.  Care  must  be  taken  not  to 
inject  more  than  an  ounce  at  a  time,  and  to  allow  the  patient  to  breathe 
between  each  deglutition.  So  extreme  a  measure  will  seldom  be 
required  if  the  patient  have  experienced  attendants  who  can  overcome 
her  resistance  to  food  by  gentler  means ;  but  it  may  be  essential,  and 
it  is  far  better  to  employ  it  than  to  allow  the  patient  to  become  ex- 
hausted from  want  of  nourishment.  In  one  case  I  had  to  feed  a  patient 
in  this  way  three  times  a  day  for  several  weeks,  and  used  for  the 
purpose  a  contrivance  known  in  asylums  as  Paley's  feeding-bottle, 
which  reduced  the  difficulty  of  the  process  to  a  minimum.  Beef-tea 
or  strong  soup,  mixed  with  some  farinaceous  material,  such  as  Reva- 
lenta  Arabica  or  wheaten  flour,  or  milk,  forms  the  best  mess  for  this 
purpose. 

In  the  early  stages  the  patient  is  probably  better  without  stimulants, 
which  seem  only  to  increase  the  excitement.  As  the  disease  progresses 
and  exhaustion  becomes  marked,  it  may  be  necessary  to  have  recourse 
to  them.  In  melancholia  they  seem  to  be  more  useful,  and  may  be 
administered  with  greater  freedom. 

The  state  of  the  bowels  requires  especial  attention.  They  are  almost 
always  disordered,  the  evacuations  being  dark  and  offensive  in  odor. 
In  the  early  stages  of  the  disease  the  prompt  clearing  of  the  bowels  by 
a  suitable  purgative  sometimes  has  the  effect  of  cutting  short  an  im- 
pending attack.  A  curious  example  of  this  is  recorded  by  Gooch,  in 
which  the  patient's  recovery  seemed  to  date  from  the  free  evacuation 
of  the  bowels.  A  few  grains  of  calomel,  or  a  dose  of  compound  jalap 
powder,  or  of  castor  oil,  may  generally  be  readily  given.  During  the 
continuance  of  the  illness  the  state  of  the  primae  vise  should  be  attended 
to,  and  occasional  aperients  will  be  useful,  but  strong  and  repeated 
purgation  is  hurtful  from  the  debility  it  produces. 

One  of  the  most  important  points  of  treatment  is  to  procure  sleep. 
For  this  purpose  there  is  no  drug  so  valuable  as  the  hydrate  of  choral, 
either  alone  or  in  combination  with  bromide  of  potassium,  which  has 
a  distinct  effect  in  increasing  its  hypnotic  action.  Given  in  a  full  dose 
at  bedtime,  say  from  fifteen  grains  to  half  a  drachm,  it  rarely  fails  in 
procuring  at  least  some  sleep,  and  in  an  early  stage  of  acute  mania 
this  may  be  followed  by  the  best  effects.  It  may  be  necessary  to 


622  THE    PUERPERAL    STATE. 

repeat  this  draught  •  night  after  night,  during  the  acute  stage  of  the 
malady.  If  we  cannot  induce  the  patient  to  smallow  the  medicine  it 
may  be  given  in  the  form  of  enema. 

It  is  generally  admitted  that  in  mania,  preparations  of  opium,  for- 
merly much  relied  on  in  the  treatment  of  the  disease,  are  apt  to  do 
more  harm  than  good.  Dr.  Blandford  gives  a  strong  opinion  on  this 
point.  He  says :  "  In  prolonged  delirious  mania  I  believe  opium 
never  does  good,  and  may  do  great  harm.  We  shall  see  the  effects  of 
narcotic  poisoning  if  it  be  pushed,  but  none  that  are  beneficial.  This 
applies  equally  to  opium  given  by  the  mouth  and  by  subcutaneous 
injection.  The  latter,  as  it  is  more  certain  and  effectual  in  producing 
good  results,  is  also  more  deadly  when  it  acts  as  a  narcotic  poison. 
After  the  administration  of  a  dose  of  morphia  by  the  subcutaneous 
method,  the  patient  will  probably  at  once  fall  asleep,  and  we  con- 
gratulate ourselves  that  our  long-wished -for  object  is  attained.  But 
after  half  an  hour  or  so  the  sleep  suddenly  terminates,  and  the  mania 
and  excitement  are  worse  than  before.  Here  you  may  possibly  think 
that,  had  the  dose  been  larger,  instead  of  half  an  hour's  sleep  you 
would  have  obtained  one  of  longer  duration,  and  you  may  administer 
more,  but  with  a,  like  result.  Large  doses  of  morphia  not  merely  fail 
to  produce  refreshing  sleep ;  they  poison  the  patient,  and  produce,  if 
not  the  symptoms  of  actual  narcotic  poisoning,  at  any  rate  that  typhoid 
condition  which  indicates  prostration  and  approaching  collapse.  I 
believe  there  is  no  drug  the  use  of  which  more  often  becomes  abused 
than  that  of  opium."  It  is  otherwise  in  cases  of  melancholia,  espe- 
cially in  the  more  chronic  forms.  In  these,  opiates  in  moderate  doses, 
not  pushed  to  excess,  may  be  given  with  great  advantage.  The  sub- 
cutaneous injection  of  morphia  is  by  far  the  best  means  of  exhibiting 
the  drug,  from  its  rapidity  of  action  and  facility  of  administration. 

There  are  other  methods  of  calming  the  excitement  of  the  patient 
besides  the  use  of  medicines.  The  prolonged  use  of  the  warm  bath, 
the  patient  being  immersed  in  water  at  a  temperature  of  90°  or  92° 
for  at  least  half  an  hour,  is  highly  recommended  by  some  as  a  sedative. 
The  wet  pack  serves  the  same  purpose,  and  is  more  readily  applied  in 
refractory  subjects. 

Judicious  nursing-  is  of  primary  importance.  The  patient  should 
be  kept  in  a  cool,  well-ventilated,  and  somewhat  darkened  room.  If 
possible  she  should  remain  in  bed,  or,  at  least,  endeavors  should  be 
made  to  restrain  the  excessive  restless  motion  which  has  so  much  effect 
in  promoting  exhaustion.  The  presence  of  relatives  and  friends,  espe- 
cially the  husband,  has  generally  a  prejudicial  and  exciting  effect;  and 
it  is  advisable  to  place  the  patient  under  the  care  of  nurses  experienced 
in  the  management  of  the  insane,  who,  as  strangers,  are  likely  to  have 
more  control  over  her.  It  is  not  too  much  to  say  that  much  of  the 
success  in  treatment  must  depend  on  the  manner  in  which  this  indica- 
tion is  met.  Rough,  unskilled  nurses,  who  do  not  know  how  to  use 
gentleness  combined  with  firmness,  will  certainly  aggravate  and  pro- 
long the  disorder.  Inasmuch  as  no  patient  should  be  left  un watched 
by  day  or  night,  more  than  one  nurse  is  essential. 

The  question  of  the  removal  of  the  patient  to  an  asylum  is  one 


PUERPERAL    SEPTICAEMIA.  623 

which  will  give  rise  to  anxious  consideration.  As  the  fact  of  having 
been  under  such  restraint  of  necessity  fixes  a  certain  lasting  stigma  upon 
a  patient,  this  is  a  step  which  everyone  would  wish  to  avoid  if  possible. 
In  cases  of  acute  mania,  which  will  probably  last  a  comparatively 
short  time,  home  treatment  can  generally  be  efficiently  carried  out. 
Much  must  depend  on  the  circumstances  of  the  patient.  If  these  be 
of  a  nature  which  preclude  the  possibility  of  her  obtaining  thoroughly 
efficient  nursing  and  treatment  in  her  own  home,  it  is  advisable  to 
remove  her  to  a  place  where  these  essentials  can  be  obtained,  even  at 
the  cost  of  some  subsequent  annoyance.  In  cases  of  chronic  melan- 
cholia, the  management  of  which  is  on  the  whole  more  difficult,  the 
necessity  for  such  a  measure  is  more  likely  to  arise,  and  should  not  be 
postponed  too  late.  Many  examples  of  incurable  dementia  arising  out 
of  puerperal  melancholia  can  be  traced  to  unnecessary  delay  in  placing 
the  patients  under  the  most  favorable  conditions  for  recovery. 

Treatment  during  Convalescence. — When  convalescence  is  com- 
mencing, change  of  air  and  scene  will  often  be  found  of  great  value. 
Removal  to  some  quiet  country  place,  where  the  patient  can  enjoy 
abundance  of  air  and  exercise,  in  the  company  of  her  nurses,  without 
the  excitement  of  seeing  many  people,  is  especially  to  be  recommended. 
Great  caution  must  be  used  in  admitting  the  visits  of  relatives  and 
friends.  In  two  cases  under  my  own  care  the  patients  relapsed,  when 
apparently  progressing  favorably,  because  the  husbands  insisted,  con- 
trary to  advice,  on  seeing  them.  On  the  other  hand,  Gooch  has 
pointed  out  that  when  the  patient  is  not  recovering,  when  month  after 
month  has  been  passed  in  seclusion  without  any  improvement, 'the 
visit  of  a  friend  or  relative  may  produce  a  favorable  moral  impression 
and  inaugurate  a  change  for  the  better.  It  is  probably  in  cases  of 
melancholia,  rather  than  in  mania,  that  this  is  likely  to  happen.  The 
experiment  may,  under  such  circumstances,  be  worth  trying  ;  but  it  is 
one  the  result  of  which  we  must  contemplate  with  some  anxiety. 


CHAPTER   V. 

PUERPERAL  SEPTICAEMIA. 

Difference  of  Opinion  as  to  Puerperal  Fever. — There  is  no  subject 
in  the  whole  range  of  obstetrics  which  has  caused  so  much  discussion 
and  difference  of  opinion  as  that  to  which  this  chapter  is  devoted. 
Under  the  name  of  puerperal  fever,  the  disease  we  have  to  consider  has 
given  rise  to  endless  controversy.  One  writer  after  another  has  stated 
his  view  of  the  nature  of  the  affection  with  dogmatic  precision,  often 
on  no  other  grounds  than  his  own  preconceived  notions  and  an 
erroneous  interpretation  of  some  of  the  post-mortem  appearances. 


624  THE    PUERPERAL    STATE. 

Thus,  one  states  that  puerperal  fever  is  only  a  local  inflammation, 
such  as  peritonitis ;  others  declare  it  to  be  phlebitis,  metritis,  metro- 
peritonitis,  or  an  essential  zymotic  disease  sui  generis,  which  affects 
lying-in  women  only.  The  result  has  been  a  hopeless  confusion ;  and 
the  student  rises  from  the  study  of  the  subject  with  little  more  useful 
knowledge  than  when  he  began.  Fortunately,  modern  research  i& 
beginning  to  throw  a  little  light  upon  this  chaos. 

Modern  View  of  the  Disease. — The  whole  tendency  of  recent  in- 
vestigation is  daily  rendering  it  more  and  more  certain  that  obstetri- 
cians have  been  led  into  error  by  the  special  virulence  and  intensity  of 
the  disease,  and  that  they  have  erroneously  considered  it  to  be  some- 
thing special  to  the  puerperal  state,  instead  of  recognizing  in  it  a  form 
of  septic  disease  practically  identical  with  that  which  is  familiar  to  sur- 
geons under  the  name  of  pyaemia  or  septicaemia,  generally  produced 
by  the  pathogenic  infection  of  lesions  of  continuity  in  the  parturient 
canal,  resulting  from  separation  of  the  decidua  and  placenta,  or  from 
lacerations  of  the  cervix,  vagina,  or  perineum. 

If  this  view  be  correct,  the  term  "  puerperal  fever,"  conveying  the 
idea  of  a  fever  such  as  typhus  or  typhoid,  must  be  acknowledged  to 
be  misleading,  and  one  that  should  be  discarded,  as  only  tending  to 
confusion.  Before  discussing  at  length  the  reasons  which  render  it 
probable  that  the  disease  is  in  no  way  specific  or  peculiar  to  the  puer- 
peral state,  it  will  be  well  to  relate  briefly  some  of  the  leading  facts 
connected  with  it. 

History. — More  or  less  distinct  references  to  the  existence  of  the 
so-called  puerperal  fever  are  met  with  in  the  classical  authors,  prov- 
ing beyond  doubt  that  the  disease  was  well  known  to  them ;  and 
Hippocrates,  besides  relating  several  cases,  the  nature  of  which  is  un- 
questionable, clearly  recognizes  the  possibility  of  its  originating  in  the 
retention  and  decomposition  of  portions  of  the  placenta.  Harvey  and 
other  writers  showed  that  they  were  more  or  less  familiar  with  it,  and 
even  made  most  creditable  observations  on  its  etiology  ;  the  actual  name 
'"puerperal  fever"  was  first  used  by  Strother1  in  1716,  but  it  was  not 
until  the  latter  half  of  the  last  century  that  it  came  prominently  into 
notice.  At  that  time  the  frightful  mortality  occurring  at  some  of  the 
principal  lying-in  hospitals,  especially  in  the  Hotel  Dieu  at  Paris, 
attracted  attention,  and  ever  since  the  disease  has  been  familiar  to 
obstetricians. 

Mortality  in  Lying-in  Hospitals. — Its  prevalence  in  hospitals  in 
which  lying-in  women  are  congregated  has  been  constantly  observed 
both  in  this  country  and  abroad,  occasionally  producing  an  appalling 
death-rate ;  the  disease,  when  once  it  has  appeared,  frequently  spread- 
ing from  one  patient  to  another  in  spite  of  all  that  could  be  done  to 
arrest  it.  It  would  be  easy  to  give  many  startling  instances  of  this. 
Thus  it  prevailed  in  London  in  the  years  1760,  1768,  and  1770  to 
such  an  extent  that  in  some  lying-in  institutions  nearly  all  the  patients 
died.  Of  the  Edinburgh  Infirmary,  in  1773,  it  is  stated  that  "almost 
every  woman,  as  soon  as  she  Avas  delivered,  or  perhaps  about  twenty- 

1  Criticon  Febrium,  1716. 


PUERPERAL    SEPTICAEMIA.  625 

four  hours  after,  was  seized  with  it,  and  all  of  them  died,  though  every 
effort  was  made  to  cure  the  disorder."  On  the  Continent,  wrhere  the 
lying-in  institutions  are  on  a  much  larger  scale,  the  mortality  was 
equally  great,  Thus  in  the  Maison  d'Accouchements  of  Paris,  in  a 
number  of  different  years,  sometimes  as  many  as  1  in  3  of  the  women 
delivered  died ;  on  one  occasion  10  women  dying  out  of  15  delivered. 
Similar  results  were  observed  in  other  great  Continental  hospitals,  as 
in  Vienna,  where,  in  1823,  19  per  cent,  of  the  cases  died,  and  in  1842, 
16  per  cent.  ;  and  in  Berlin,  in  1862,  hardly  a  single  patient  escaped, 
the  hospital  being  eventually  closed. 

Such  facts,  the  correctness  of  which  is  beyond  any  question,  prove 
to  demonstration  the  great  risk  which  may  accompany  the  aggregation 
of  lying-in  women.  It  is  to  be  observed,  however,  that  the  cases  in 
which  the  disease  produced  such  disastrous  results  occurred  before  our 
more  recent  knowledge  of  its  mode  of  propagation  was  acquired,  when 
no  sufficient  hygienic  precautions  were  adopted,  when  ventilation  was 
little  thought  of,  and  when,  in  a  word,  every  condition  prevailed  that 
would  tend  to  favor  the  spread  of  a  contagious  disease  from  one  patient 
to  another.  More  recent  experience  proves  that,  when  the  contrary  is 
the  case,  the  occurrence  of  epidemics  of  this  kind  may  be  entirely  pre- 
vented, and  the  mortality  approximated  to  that  of  the  best  class  of 
home  practice.  The  results  almost  universally  obtained  of  late  years 
by  the  introduction  of  strict  antisepsis  into  lying-in  institutions  afford 
a  most  instructive  commentary  upon  the  causes  of  puerperal  fever. 
Thus,  in  the  Maternite,  in  Paris,  the  mortality  from  1858  to  1870 
was  1  in  11 ;  at  the  present  time  it  is  only  1  in  100.  At  the  Foundling 
Hospital  in  St.  Petersburg  the  mortality  before  the  introduction  of 
antiseptics  \vas  1  in  27;  since  their  use  1  in  147.  Similar  satisfactory 
results  have  been  reported  in  lying-in  institutions  in  London,  and 
in  America — indeed  universally  wherever  antiseptic  precautions  have 
been  adopted.1  There  is,  indeed,  no  more  striking  chapter  in  the  history 
of  modern  medicine  than  this.  Formerly  a  wroman  who  was  delivered 
in  a  lying-in  hospital  ran  a  risk  not  far  short  of  some  of  the  capital 
operations ;  now  she  is  as  safe  in  one  of  them,  perhaps  safer,  than  if 
she  was  confined  in  one  of  the  most  sumptuous  of  private  houses. 

The  more  closely  the  history  of  these  outbreaks  in  hospitals  is 
studied,  the  more  apparent  does  it  become  that  that  they  are  not 
dependent  on  any  miasm  necessarily  produced  by  the  aggregation  of 
puerperal  patients,  but  on  the  direct  conveyance  of  septic  matter  from 
one  patient  to  another. 

In  numerous  instances  the  disease  has  been  said  to  be  generally 
epidemic  in  domiciliary  practice,  much  in  the  same  way  as  scarlet 
fever  or  any  zymotic  complaint  might  be.  Such  epidemics  are 
described  as  having  occurred  in  London  in  1827-28,  in  Leeds  in 
1809-12,  in  Edinburgh  in  1825,  and  many  others  might  be  cited. 
There  is,  however,  no  sufficient  ground  for  believing  that  the  disease 
has  ever  been  epidemic  in  the  strict  sense  of  the  word.  That  numerous 
cases  have  often  occurred  in  the  same  place  and  at  the  same  time  is 

1  See  "  The  Prevention  of  Lying-in  Fever,"  by  Vassily  Sutugin,  Edin.  Med.  Journ.,  vol.  1884-85, 
p.  781. 

40 


626  THE    PUERPERAL    STATE. 

beyond  question ;  but  this  can  easily  be  explained  without  admitting 
an  epidemic  influence — knowing,  as  we  do,  how  readily  septic  matter 
may  be  conveyed  from  one  patient  to  another.  In  many  of  the  so- 
called  epidemics  the  disease  has  been  limited  to  the  patients  of  certain 
mid  wives  or  practitioners,  while  those  of  others  have  entirely  escaped  : 
a  fact  easily  understood  on  the  assumption  of  the  disease  being  pro- 
duced by  septic  matter  conveyed  to  the  patient,  but  irreconcilable  witb 
the  view  of  general  epidemic  influence.  We  are  not  in  possession  of 
any  reliable  statistics  of  the  mortality  arising  from  puerperal  septi- 
caemia in  ordinary  general  practice.  It  has,  however,  been  well  pointed 
out  in  the  Report  on  Puerperal  Fever,  presented  by  the  Obstetrical 
Society  of  Berlin  to  the  Prussian  Minister  of  Health,1  that  not  only 
do  the  published  returns  of  death  from  metria  afford  no  reliable  esti- 
mate of  the  actual  mortality  from  this  source,  but  that  they  are  very 
far  more  numerous  than  deaths  from  any  other  cause  in  connection 
with  pregnancy  and  childbirth. 

Theories  advanced  regarding  its  Nature. — It  would  be  a  useless 
task  to  detail  at  length  the  theories  that  have  been  advanced  to  explain 
the  disease.  Indeed,  it  may  safely  be  held  that  the  supposed  necessity 
of  providing  a  theory  which  would  explain  all  the  facts  of  the  disease 
has  done  more  to  surround  it  with  obscurity  than  even  the  difficulties 
of  the  subject  itself.  If  any  real  advance  is  to  be  made,  it  can  only  be 
by  adopting  a  humble  attitude,  by  admitting  that  we  are  only  on  the 
threshold  of  the  inquiry,  and  by  a  careful  observation  of  clinical  facts, 
without  drawing  from  them  too  positive  deductions. 

Theory  of  its  Local  Origin. — Many  have  taught  that  the  disease 
is  essentially  a  local  inflammation,  producing  secondary  constitutional 
effects.  This  view  doubtless  originated  from  too  exclusive  attention 
to  the  morbid  changes  found  on  post-mortem  examination.  Extensive 
peritonitis,  phlebitis,  inflammation  of  the  lymphatics  or  of  the  -tissues 
of  the  uterus,  are  very  commonly  found  after  death ;  and  each  of  these 
has,  in  its  turn,  been  believed  to  be  the  real  source  of  the  disease.  This 
view  finds  but  little  favor  with  modern  pathologists,  and  is  in  so  many 
ways  inconsistent  with  clinical  facts  that  it  may  be  considered  to  be 
obsolete.  No  one  of  the  conditions  above  mentioned  is  universally 
found,  and  in  the  worst  cases  definite  signs  of  local  inflammation  may 
be  entirely  absent.  Nor  will  this  theory  explain  the  conveyance  of 
the  disease  from  one  patient  to  another,  or  the  peculiar  severity  of  the 
constitutional  symptoms. 

Theory  of  an  Essential  Zymotic  Fever. — A  more  admissible 
theory,  and  one  which  has  been  extensively  entertained,  is  that  there 
is  an  essential  zymotic  fever  peculiar  to,  and  only  attacking  puerperal 
women,  which  is  as  specific  in  its  nature  as  typhus  or  typhoid,  and  to 
which  the  local  phenomena  observed  after  death  bear  the  same  relation 
that  the  pustules  on  the  skin  do  to  smallpox,  or  the  ulcers  in  the 
intestinal  glands  to  typhoid.  This  fever  is  supposed  to  spread  by  con- 
tagion and  infection,  and  to  prevail  epidemically  both  in  private  and 
in  hospital  practice.  The  most  recent  exponent  of  this  view,  Fordyce 

1  "  Denkschrift  der  Puerperalfieber-Commission,"  Zeitschrift  f.  Geb.  u.  Gyn.,  1878,  Band  iii.  S.  1 
translated  in  Ediu.  Med.  Journ.,  vol.  1878-79,  p.  435. 


PUERPERAL  SEPTICAEMIA.  627 

Barker,  in  his  excellent  work  on  the  Puerperal  Diseases,  entered 
at  length  into  all  the  theories  of  the  disease.  He,  like  all  others 
holding  his  opinions,  entirely  failed,  I  cannot  but  think,  to  bring 
forward  any  conclusive  evidence  of  the  existence  of  such  a  specific 
fever.  It  is  no  doubt  true  that  in  typhus  and  typhoid,  and  other 
undoubted  examples  of  this  class  of  disease,  there  are  well-marked 
local  secondary  phenomena ;  but  then  they  are  distinct  and  constant. 
He  makes  no  attempt  to  prove  that  anything  of  the  kind  occurs  in 
puerperal  fever.  On  the  contrary,  probably  there  are  no  two  cases  in 
which  similar  local  phenomena  occur;  nor  is  there  any  case  in  which 
the  most  practised  obstetrician  could  foretell  either  the  course  and 
duration  of  the  illness  or  the  local  phenomena.  Again,  this  theory 
altogether  fails  to  explain  the  very  important  class  of  cases  which  can 
be  distinctly  traced  to  the  absorption  of  septic  matter  from  decompos- 
ing coagula  and  the  like.  Barker  meets  this  difficulty  by  placing  such 
cases  under  a  separate  category,  admitting  that  they  are  examples  of 
septicaemia.  But  he  fails  to  show  any  difference  in  symptomatology 
or  post-mortem  signs  between  them  and  the  cases  that  he  believes  to 
depend  on  an  essential  fever ;  nor  would  it  be  possible  to  distinguish 
the  one  from  the  other  by  either  their  clinical  or  pathological  history. 

Theory  of  its  Identity  with  Surgical  Septicaemia. — The  modern 
view,  which  holds  that  the  disease  is,  in  fact,  identical  with  the  con- 
dition known  as  pyaemia  or  septicaemia,  is  by  no  means  free  from 
objections,  and  much  patient  clinical  investigation  is  required  to  give 
a  satisfactory  explanation  of  certain  peculiarities  which  the  disease 
presents ;  but  in  spite  of  these  difficulties,  which  time  may  serve  to 
remove,  it  offers  a  far  better  explanation  of  the  phenomena  observed 
than  any  other  that  has  yet  been  advanced. 

According  to  this  theory,  the  so-called  puerperal  fever  is  produced 
by  the  absorption  of  septic  matter  into  the  system,  through  solutions 
of  continuity  in  the  generative  tract,  such  as  always  exist  after  labor. 
It  is  not  essential  that  the  poison  should  be  peculiar  or  specific ;  for, 
just  as  in  surgical  pyaemia,  any  decomposing  organic  matter  may  set 
up  the  morbid  action. 

In  describing  the  disease  under  discussion,  I  shall  assume  that,  so 
far  as  our  present  knowledge  goes,  this  view  is  the  one  most  consonant 
with  facts ;  but,  bearing  in  mind  that  very  little  is  yet  known  of 
surgical  septicaemia,  it  must  not  be  expected  that  obstetricians  can 
satisfactorily  explain  all  the  phenomena  they  observe. 

The  best  basis  of  description  I  know  of  is  that  given  by  Burdon 
Sanderson,  when  he  says:  "  In  every  pyaemic  process  you  may  trace  a 
focus,  a  centre  of  origin,  lines  of  diffusion  or  distribution,  and  secondary 
results  from  the  distribution.  In  every  case  an  initial  process  from 
which  infection  commences,  from  which  the  infection  spreads,  and 
secondary  processes  which  come  out  of  this  primary  one."1  Adopting 
this  division,  I  shall  first  treat  of  the  mode  in  which  the  infection  may 
commence  in  obstetric  cases,  and  point  out  special  difficuties  which 
this  part  of  the  subject  presents. 

i  Clinical  Transactions,  vol.  vii.  p.  108. 


628  THE    PUERPERAL    STATE. 

Channels  through  which  Septic  Matter  may  be  Absorbed. — 
The  fact  that  all  recently  delivered  women  present  lesions  of  continuity 
in  the  generative  tract,  through  which  septic  matter  brought  into  con- 
tact with  them  may  be  readily  absorbed,  has  long  been  recognized. 
The  analogy  between  the  interior  of  the  uterus  after  delivery  and  the 
surface  of  a  stump  after  amputation  was  particularly  insisted  on  by 
Cruveilhier,  Simpson,  and  others — an  analogy  which  was,  to  a  great 
extent,  based  on  erroneous  conceptions  of  what  took  place — since  they 
conceived  that  the  whole  interior  of  the  uterus  Avas  bared.  It  is  now 
well  known  that  such  is  not  the  case ;  but  the  fact  remains  that  at  the 
placental  site,  at  any  rate,  there  are  open  vessels  through  which  absorp- 
tion may  readily  take  place.  That  absorption  of  septic  material  occurs 
through  this  channel  is  probable  in  certain  cases  in  \vhich  decomposing 
materials  exist  in  the  interior  of  the  uterus,  especially  when,  from 
defective  uterine  contraction,  the  venous  sinuses  are  abnormally  patu- 
lous  and  are  not  occluded  by  thrombi.  It  is  difficult  to  understand 
how  septic  matter  introduced  from  without  can  reach  the  placental  site. 
Other  sites  of  absorption  are,  however,  always  available.  These  exist 
in  every  case  in  the  form  of  slight  abrasions  or  lacerations  about  the 
cervix  or  in  the  vagina,  or,  especially  in  primipane,  about  the  four- 
chette  and  perineum.  There  is  even  some  reason  to  think  that  absorp- 
tion of  septic  matter  may  take  place  through  the  mucous  membrane  of 
the  vagina  or  cervix  without  any  breach  of  surface.  This  might  serve 
to  account  for  the  occasional,  though  rare,  cases  in  which  the  symptoms 
of  the  disease  develop  themselves  before  delivery,  or  so  soon  after  it  as 
to  show  that  the  infection  must  have  preceded  labor ;  nor  is  there  any 
inherent  improbability  in  the  supposition  that  septic  material  may  be 
occasionally  absorbed  through  the  unbroken  mucous  membrane,  as  is 
certainly  the  case  with  some  poisons,  for  example  that  of  syphilis. 
Hence  there  is  no  difficulty  in  recognizing  the  similarity  of  a  lying-in 
woman  to  a  patient  suffering  from  a  recent  surgical  lesion,  or  in  under- 
standing how  septic  matter  conveyed  to  her,  during  or  shortly  after 
labor,  may  be  absorbed.  It  is  necessary,  however,  to  suppose  that 
absorption  takes  place  immediately  or  very  shortly  after  these  lesions 
of  continuity  are  formed,  for  it  is  well  known  that  the  power  of  absorp- 
tion is  arrested  after  they  have  commenced  to  heal.  This  fact  may 
explain  the  cases  in  which  sloughing  about  the  perineum  or  vagina 
exists  without  any  septicaemia  resulting,  or  the  far  from  uncommon 
cases  in  which  an  intensely  fetid  lochial  discharge  may  be  present  a 
few  days  after  delivery  without  any  infection  taking  place. 

The  character  and  sources  of  the  septic  matter  constitute  one  of  the 
most  obscure  questions  in  connection  with  septicaemia,  and  that  which 
is  most  open  to  discussion. 

Division  into  Autogenetic  and  Heterogenetic  Cases. — A  popular 
division  of  the  subject  has  been  into  cases  in  which  the  septic  matter 
originates  within  the  patient,  so  that  she  infects  herself,  the  disease 
.then  being  autogendic;  and  into  those  in  which  the  septic  matter  is 
conveyed  from  without  and  brought  into  contact  with  absorptive  sur- 
faces in  the  generative  tract,  the  disease  then  being  heterogenetic. 

Of  late  the  term  autogeuetic  has  been  objected  to  on  the  ground 


PUERPERAL    SEPTICAEMIA.  629 

that  retained  coagula  and  the  like,  contained  within  the  person  of  the 
patient,  would  not  of  themselves  decompose  and  give  rise  to  infec- 
tion unless  microbes  had  found  their  way  to  them  from  without  and 
set  up  decomposition.  In  this  strict  sense  the  word  may  be  admitted 
to  be  inaccurate.  At  the  same  time  the  division  \vas  a  very  practical 
one,  and  it  laid  stress  on  the  danger  of  leaving  organic  structures, 
such  as  portions  of  placenta,  membranes,  or  clots,  within  the  genital 
tract.  With  this  explanation,  therefore,  the  division  may  be  retained. 
It  is  supposed  that  disease  of  this  type  originates  from  saprsemic  in- 
toxication due  to  the  absorption  of  poisonous  materials  resulting 
from  putrefactive  changes,  but  that  it  differs  from  the  septic  infec- 
tion, inasmuch  as  organisms  do  not  invade  the  tissues  and  multiply 
in  them.  Clinically,  however,  the  two  "types  of  disease  cannot  be 
distinctly  differentiated,  and  it  is  admitted  that  they  may  be  com- 
bined, true  pathogenic  micrococci  finding  a  congenial  soil  in  the 
decomposing  structures,  and  subsequently  invading  the  tissues.  The 
former  class  of  disease  may  be  termed  saprcemia,  corresponding  to  cases 
which  have  been  described  as  autogenetic ;  the  latter  septicaemia,  corre- 
sponding to  the  heterogenetic  type. 

Sources  of  Sapraemia  or  Self-infection. — The  sources  of  sapramia 
may  be  various,  but  they  are  not  difficult  to  understand.  Any  condi- 
tion giving  rise  to  decomposition,  either  of  the  tissues  of  the  mother 
herself,  of  matters  retained  in  the  uterus  or  vagina  that  ought  to  have 
been  expelled,  or  decomposing  matter  derived  from  a  putrid  foetus, 
may  start  the  the  septicaemic  process.  Thus  it  may  happen  that  from 
continuous  pressure  on  the  maternal  soft  parts  during  labor,  sloughing 
has  set  in ;  or  there  may  be  already  decomposing  material  present  from 
some  previous  morbid  state  of  the  genital  tract,  as  in  carcinoma.  A 
more  common  origin  is  the  retention  of  coagula,  or  of  small  portions 
of  membrane,  or  of  placenta,  in  the  interior  of  the  uterus,  which  have 
putrefied  from  access  of  air;  or  in  the  decomposition  of  the  lochia. 
That  the  retention  of  portions  of  the  placental  tissue  has  at  all  times 
been  the  cause  of  septicaemia  may  be  illustrated  by  the  case  of  the 
Duchesse  d'Orleans  (in  the  time  of  Louis  XIII.),  who  had  an  easy 
labor,  but  died  of  childbed  fever.  An  examination  was  made  by  the 
leading  physicians  of  Paris,  in  their  report  of  which  it  was  stated: 
"On  the  right  side  of  the  womb  was  found  a  small  portion  of  after- 
birth, so  firmly  adherent  that  it  could  hardly  be  torn  off  by  the  finger- 
nails."1 The  reason  why  self-infection  does  not  more  often  occur 
from  such  sources,  since  more  or  less  decomposition  is  of  necessity  so 
often  present,  has  already  been  referred  to  in  the  fact  that  absorption 
of  such  matters  is  not  apt  to  occur  when  the  lesions  of  continuity, 
always  existing  after  parturition,  have  commenced  to  heal.  This 
observation  may  also  serve  to  explain  how  previous  bad  states  of 
health,  by  interfering  with  the  healthy  reparative  process  occurring 
after  delivery,  may  predispose  to  self-infection.  It  is  interesting  to 
note  that  puerperal  septicaemia,  arising  from  such  sources,  is  not  lim- 
ited to  the  human  race.  In  the  debate  on  pyaemia  at  the  Clinical 

1  Louise  Bourgeois,  by  Goodell. 


630  THE    PUERPERAL    STATE. 

Society,  Mr.  Hutchinson  recorded  several  well-marked  examples 
occurring  in  ewes,  in  whose  uteri  portions  of  retained  placenta  were 
found. 

Source  of  Heterogenetic  Infection. — The  sources  of  septic  matter 
conveyed  from  without  are  much  more  difficult  to  trace,  and  there  are 
many  facts  connected  with  heterogenetic  infection  which  are  very  diffi- 
cult to  reconcile  with  theory,  and  of  which,  it  must  be  admitted,  we 
are  not  yet  able  to  give  a  satisfactory  explanation. 

It  is  probable  that  any  decomposing  organic  matter  may  infect,  but 
that  some  forms  operate  with  more  certainty  and  greater  virulence 
than  others. 

One  of  these,  which  has  attracted  special  attention,  is  what  may  be 
termed  cadaveric  poison,  derived  from  dissection  of  the  dead  subject 
in  the  anatomical  and  post-mortem  theatres,  and  conveyed  to  the 
genital  tract  by  the  hands  of  the  accoucheur.  Attention  was  particu- 
larly directed  to  this  source  of  infection  by  the  observations  of  Sem- 
melweiss,  who  showed  that  in  the  division  of  the  Vienna  Lying-in 
Hospital  attended  by  medicaT  men  and  students  who  frequented  the 
dissecting-rooms  the  mortality  was  seldom  less  than  one  in  ten,  while 
in  the  division  solely  attended  by  women  the  mortality  never  exceeded 
one  in  thirty-four;  the  number  of  deaths  in  the  former  division  at 
once  falling  to  that  of  the  latter  so  soon  as  proper  precautions  and 
means  of  disinfection  were  used.  Many  other  facts  of  a  like  nature 
have  since  been  recorded  which  render  this  origin  of  puerperal  septi- 
caemia a  matter  of  certainty.  An  interesting  example  is  related  by 
Simpson  with  characteristic  candor:  "In  1836  or  1837,  Mr.  Sidey,  of 
this  city,  had  a  rapid  succession  of  five  or  six  cases  of  puerperal  fever 
in  his  practice,  at  a  time  when  the  disease  was  not  known  to  exist  in 
the  practice  of  any  other  practitioners  in  the  locality.  Dr.  Simpson, 
who  had  then  no  firm  or  proper  belief  in  the  contagious  propagation 
of  puerperal  fever,  attended  the  dissection  of  Mr.  Sidey's  patients 
and  freely  handled  the  diseased  parts.  The  next  four  cases  of  mid- 
wifery which  Dr.  Simpson  attended  were  all  affected  with  puerperal 
fever,  and  it  was  the  first  time  he  had  seen  it  in  practice.  Dr.  Patter- 
son, of  Leith,  examined  the  ovaries,  etc.  The  next  three  cases  which 
Dr.  Patterson  attended  in  that  town  were  attacked  with  the  disease." ' 
Negative  examples  are  of  course  brought  forward,  of  those  who  have 
attended  post-mortem  examinations  without  injury  to  their  obstetric 
patients,  which  merely  prove  that  the  cadaveric  poison  does  not,  of 
necessity,  'attach  itself  to  the  hands  of  the  dissector ;  no  amount  of 
such  testimony  can  invalidate  such  positive  evidence  as  that  just 
narrated.  Barnes  believes  that  there  is  not  so  much  danger  attending 
the  dissection  of  patients  who  have  died  of  any  ordinary  disease,  but 
that  the  risk  attending  the  dissection  of  those  who  have  died  of  infec- 
tious or  contagious  complaints  is  very  great  indeed.2  I  presume  there 
is  no  doubt  that  the  risk  is  greater  when  the  subject  has  died  from 
zymotic  disease ;  but  the  distinction  is  too  delicate  to  rely  on,  and  the 
attendant  on  midwifery  will  certainly  err  on  the  safe  side  by  avoiding 

1  Selected  Obstetric  Works,  p.  508. 

8  "  Lectures  on  Puerperal  Fever  "  Lancet,  1865,  vol.  ii.  p.  112. 


PUERPERAL    SEPTICJ3MIA.  631 

as  much  as  possible  having  anything  to  do  with  the  conduct  of  dissec- 
tions or  post-mortem  examinations. 

Infection  from  Erysipelas. — Another  possible  source  of  infection 
is  erysipelatous  disease  in  all  its  forms.  The  intimate  connection 
between  erysipelas  and  surgical  pyaemia  has  long  been  recognized  by 
surgeons,  and  the  influence  of  erysipelas  in  producing  puerperal  septi- 
caemia has  been  specially  observed  in  surgical  hospitals  into  which 
lying-in  patients  were  also  admitted.  Trousseau  relates  instances  of 
this  kind  occurring  in  Paris.  The  only  instance  that  I  know  of  in 
London  was  in  the  lying-in  ward  of  King's  College  Hospital,  where, 
in  spite  of  every  hygienic  precaution,  the  mortality  was  so  great  as  to 
necessitate  the  closure  of  the  ward.  Here  the  association  of  erysipelas 
with  puerperal  septicamia  was  again  and  again  observed;  the  latter 
proving  fatal  in  direct  proportion  to  the  prevalence  of  the  former  in 
the  surgical  wards.  The  dependence  of  the  two  on  the  same  poison 
was  in  one  instance  curiously  shown  by  the  fact  of  the  child  of  a 
patient  who  died  of  puerperal  septica3mia  dying  from  erysipelas. which 
started  from  a  slight  abrasion  produced  by  the  forceps.  A  more 
recent  and  very  remarkable  example  is  related  by  Dr.  Lombe  Atthill.1 
A  patient  suffering  from  erysipelas  was  admitted  into  the  Rotunda 
Hospital  on  February  15,  1877.  The  sanitary  condition  of  the  hos- 
pital was  at  the  time  excellent.  The  patient  was  removed  next  day, 
but  of  the  next  10  patients  confined  in  adjoining  wards,  9  were  attacked 
with  puerperal  peritonitis,  the  only  one  who  escaped  being  a  case  of 
abortion.  But  the  connection  between  erysipelas  and  puerperal  septi- 
caemia is  not  limited  to  hospitals,  having  been  observed  in  domiciliary 
practice.  Some  interesting  facts  have  been  collected  by  Dr.  Minor,* 
who  has  shown  that  the  two  diseases  have  frequently  prevailed 
together  in  various  parts  of  the  United  States,  and  that  during  a 
recent  outbreak  of  puerperal  fever  in  Cincinnati  it  occurred  chiefly  in 
the  practice  of  those  physicians  who  attended  cases  of  erysipelas. 
Many  children  also  died  from  erysipelas  whose  mothers  had  died  from 
puerperal  fever. 

Infection  from  other  Zymotic  Diseases. — There  is  good  reason  to 
believe  that  the  coutagium  of  other  zymotic  diseases  may  produce  a 
form  of  disease  indistinguishable  from  ordinary  puerperal  septicaemia, 
and  presenting  none  of  the  characteristic  features  of  the  specific  com- 
plaint from  which  the  contagium  was  derived.  This  is  admitted  to 
be  a  fact  by  the  majority  of  our  most  eminent  British  obstetricians, 
although  it  does  not  seem  to  be  allowed  by  Continental  authorities, 
and  it  is  strongly  controverted  by  some  writers  in  this  country.  It  is 
certainly  difficult  to  reconcile  this  with  the  theory  of  septicaemia,  and 
we  are  not  in  a  position  to  give  a  satisfactory  explanation  of  it.  I 
believe,  however,  that  the  evidence  in  favor  of  the  possibility  of 
puerperal  septicamia  originating  in  this  way  is  too  strong  to  be  assail- 
able. 

The  scarlatinal  poison  is  that  regarding  which  the  greatest  number 
of  observations  have  been  made.  Numerous  cases  of  this  kind  are  to 

1  Medical  Press  and  Circular,  January-June,  1877,  p.  339. 
*  Erysipelas  and-  Childbed  Fever.    Cincinnati,  1874. 


632  THE    PUERPERAL    STATE. 

be  found  scattered  through  our  obstetric  literature,  but  the  largest 
number  are  to  be  met  with  in  a  paper  by  Dr.  Braxton  Hicks  in  the 
twelfth  volume  of  the  Obstetrical  Transactions,  and  they  are  especially 
valuable  from  that  gentleman's  well-known  accuracy  as  a  clinical 
observer.  Out  of  68  cases  of  puerperal  disease  seen  in  consultation, 
no  less  than  37  were  distinctly  traced  to  the  scarlatinal  poison.  Of 
these  20  had  the  characteristic  rash  of  the  disease ;  but  the  remaining 
17,  although  the  history  clearly  proved  exposure  to  the  contagium  of 
scarlet  fever,  showed  none  of  its  usual  symptoms,  and  were  not  to  be 
distinguished  from  ordinary  typical  cases  of  the  so-called  puerperal 
fever.  On  the  theory  that  it  is  impossible  for  the  specific  contagious 
diseases  to  be  modified  by  the  puerperal  state,  we  have  to  admit  that 
one  physician  met  with  17  cases  of  puerperal  septicaemia  in  which,  by 
a  mere  coincidence,  the  contagion  of  scarlet  fever  had  been  traced, 
and  that  the  disease  nevertheless  originated  from  some  other  source 
— an  hypothesis  so  improbable  that  its  mere  mention  carries  its  own 
refutation. 

With  regard  to  the  other  zymotic  diseases  the  evidence  is  not  so 
strong ;  probably  from  the  comparative  rarity  of  the  diseases.  Hicks 
mentions  one  case  in  which  the  diphtheritic  poison  was  traced,  although 
none  of  the  usual  phenomena  of  the  disease  were  present.  I  lately 
saw  a  case  in  which  a  lady,  a  few  days  after  delivery,  had  a  very 
serious  attack  of  septicaemia,  without  any  diphtheritic  symptoms,  her 
husband  being  at  the  same  time  attacked  with  diphtheria  of  a  most 
marked  type.  Here  it  would  be  difficult  not  to  admit  the  dependence 
of  the  two  diseases  on  the  same  poison. 

It  is,  however,  certain  that  all  the  zymotic  diseases  may  attack  a 
newly  delivered  woman,  and  run  their  characteristic  course  without 
any  peculiar  intensity.  Probably  most  practitioners  have  seen  cases 
of  this  kind  ;  and  this  is  precisely  one  of  the  points  of  difficulty  which 
we  cannot  at  present  explain,  but  on  which  future  research  may  be 
expected  to  throw  some  light.  It  seems  to  me  not  improbable  that 
the  explanation  of  the  fact  that  zymotic  poison  may,  in  one  puerperal 
patient,  run  its  ordinary  course,  and  in  another  produce  symptoms  of 
intense  septicaemia,  may  be  found  in  the  channel  of  absorption.  It  is, 
at  any  rate,  comprehensible  that  if  the  contagium  be  absorbed  through 
the  skin  or  the  ordinary  channel,  it  may  produce  its  characteristic 
symptoms  and  run  its  usual  course ;  while,  if  brought  into  contact 
with  lesions  of  continuity  in  the  generative  tract,  it  may  act  more  in 
the  way  of  septic  poison,  or  with  such  intensity  that  its  specific  symp- 
toms are  not  developed. 

It  may  reasonably  be  objected  that  if  puerperal  and  surgical  sep- 
ticaemia be  identical,  the  zymotic  poisons  ought  to  be  similarly  modi- 
fied when  they  infect  patients  after  surgical  operations.  The  subject 
of  specific  contagium  as  a  cause  of  surgical  pyaemia  has  been  so  little 
studied,  that  I  do  not  think  anyone  would  be  justified  in  asserting  that 
such  an  occurrence  is  not  possible.  Fritsch,  of  Halle,  and  other 
German  physicians  have  recently  shown  how  elaborate  antiseptic  pre- 
cautions in  lying-in  hospitals  may  prevent  the  origin  of  the  disease 
from  such  sources.  Sir  James  Paget,  in  his  Clinical  Lectures,  seems 


PUEKPERAL    SEPTICAEMIA.  633 

to  believe  in  the  possibility  of  such  modification.  He  says:  "I  think 
it  not  improbable  that,  in  some  cases,  results  occurring  with  obscure 
symptoms,  within  two  or  three  days  after  operations,  have  been  due  to 
scarlet-fever  poison,  hindered  in  some  way  from  its  usual  progress." 
Sir  Spencer  Wells  informs  me  that  he  has  seen  cases  of  surgical  pyaemia 
which  he  had  reason  to  believe  originated  in  the  scarlatinal  poison ; 
and  his  well-known  success  as  an  ovariotomist  is,  no  doubt,  in  a  great 
measure  to  be  attributed  to  his  extreme  care  in  seeing  that  no  one 
likely  to  come  in  contact  with  his  patients  has  been  exposed  to  any 
such  source  of  infection. 

Sewer-gas  and  Defective  Sanitary  Arrangements. — Exposure 
to  sewer-gas  may,  I  feel  sure,  produce  the  disease.  In  two  cases  of 
the  kind  I  had  the  opportunity  of  closely  watching  an  untrapped 
drain  opened  directly  into  the  bedroom — in  one  instance  into  a  bath, 
in  the  other  into  a  water-closet.  Both  cases  were  indistinguishable 
from  the  ordinary  form  of  the  disease,  and  in  both  improvement  com- 
menced as  soon  as  the  patient  was  removed  into  another  room. 

In  a  case  I  saw  some  years  ago  at  Netting  Hill,  the  patient,  who 
had  been  confined  within  a  week,  had  all  the  symptoms  of  a  most 
intense  attack  of  septicaemia,  bftt  none  of  a  diphtheritic  character, 
while  her  husband  lay  in  an  adjoining  room  suffering  from  a  diphthe- 
ritic sore-throat.  Here  the  waste-pipe  of  the  bath  was  found  to  com- 
municate directly  with  the  sewer.  In  spite  of  her  intense  illness,  I 
had  the  patient  removed  to  another  house,  and  from  that  moment  she  - 
began  to  improve.  In  two  other  cases  in  which  the  same  source  of 
disease  was  detected,  the  removal  of  the  patient  from  the  infected 
atmosphere  was  immediately  followed  by  a  marked  amelioration  in  the 
symptoms.  I  know  of  three  similar  cases  Avhich  ended  fatally,  in 
which  I  have  every  reason  to  believe  that  the  cause  of  the  disease  wras 
poisoning  by  sewer-gas.  Frankenhauser  has  related  a  curious  case  of 
the  poisoning  of  four  puerperal  women  by  sewer-gas.  Gustave  Braun1 
ascribes  a  recent  mortality  in  his  clinic  of  8.87  per  cent,  to  bad  sewer- 
age, his  wards  being  in  direct  connection  Avith  the  sewerage  system  of 
the  General  Hospital,  and  near  the  closets  of  the  adjoining  barracks. 
Technical  antisepsis  had  been  as  faithfully  practised  as  is  possible 
where  instruction  has  been  given  to  midwives.  In  fact,  the  whole 
question  of  the  influence  of  defective  sanitary  conditions  on  the  puer- 
peral state  deserves  much  more  serious  study  than  it  has  ever  yet  re- 
ceived, and  I  have  long  been  satisfied  that  they  have  often  much  to  do 
with  certain  grave  forms  of  illness  in  the  lying-in  state  the  origin  of 
which  cannot  otherwise  be  traced.2 

1  Centralblatt  fiirGynak.,  1889,  No.  36. 

2  Since  the  above  was  written,  I  have  published  a  special  paper  on  this  subject  ("  Defective 
Sanitation  as  a  Cause  of  Puerperal  Disease."    Lancet,  February  5, 1887).    I  append  from  it  two 
cases,  as  I  think  the  diagrams  illustrating  this  source  of  danger  may  prove  of  interest : 

The  annexed  diagram  (Fig.  207)  represents  a  bedroom  in  a  large  house  in  a  fashionable  part  of 
the  West  End,  which  had  been  recently  taken  and  done  up  in  the  most  costly  way.  I  attended 
the  lady  of  the  house  in  her  second  confinement,  and  she  lay  in  her  bed  at  A.  Shortly  she  developed 
well-marked  septic  symptoms,  and  I  naturally  investigated  the  sanitary  state  of  the  house  to  see 
if  it  threw  any  light  on  their  origin.  I  could  find  nothing  amiss.  There  was  no  bath  or  fixed 
washstand  near  the  room,  and  the  closets  were  at  a  distance,  with  the  soil-pipe  running  down 
the  outside  wall,  as  it  should  do.  It  was  not  until  some  days  afterward  that  I  discovered  the 
extraordinary  arrangement  depicted  in  the  diagram,  which  no  one  could  possibly  have  suspected, 
and  the  knowledge  of  which  the  patient  had  given  special  directions  should  be  withheld  from 
me.  At  B  is  represented  a  very  handsome  and  innocent-looking  piece  of  furniture  which  seemed 


634 


THE    PUERPERAL    STATE. 


FIG.  207. 


Septicaemia  from  Contagion  Conveyed. — The  last  source  from 
which  septic  matter  may  be  conveyed  is  from  a  patient  suffering  from 
puerperal  septicaemia,  a  mode  of  origin  which  has,  of  late,  attracted 
special  attention.  That  this  is  the  explanation  of  the  occasional 
endemic  prevalence  of  the  disease  in  lying-in  hospitals  can  scarcely  be 
doubted.  The  theory  of  a  special  puerperal  miasm  pervading  the 
hospital  is  not  required  to  account  for  the  facts,  for  there*  are  a  hun- 
dred ways,  impossible  to  detect  or  avoid — on  the  hands  of  nurses  or 
attendants,  in  sponges,  bedpans,  sheets,  or  even  suspended  in  the 
atmosphere — in  which  septic  material  derived  from  one  patient  may 
be  carried  to  another. 

The  poison  may  be  conveyed  in  the  same  manner  from  one  private 
patient  to  another.  Of  this  there  are  many  lamentable  instances  recorded. 
Thus  it  was  mentioned  by  a  gentleman  at  the  recent  discussion  at  the 
Obstetrical  Society,  that  five  out  of  fourteen  women  he  attended  died, 
no  other  practitioner  in  the  neighborhood  having  a  case.  This  origin 

to  be  a  fixed  wardrobe,  to  which  purpose  its  ends  were  in  fact  devoted.    The  centre  door,  how- 
ever, formed  by  a  large  mirror,  opened  on  a  concealed  water-closet  (c),  which  luxury  no  one  could 

have  looked  for  in  such  a  situation.  I  subsequently 
discovered  that  this  was  a  brilliant  idea  of  the  hus- 
bandrs,  who  actually  had  had  a  special  soil-pipe 
carried  through  the  centre  of  the  house,  which  com- 
municated directly  with  the  main  drain,  with  no 
ventilation,  and  who  had  thus  contrived,  at  an  enor- 
mous cost,  to  have  a  stream  of  sewer-gas  laid  on 
close  to  his  bedside.  And  be  it  remarked  that 
builders  and  plumbers  had  carried  out  this  inge- 
niously dangerous  arrangement  without  giving  the 
slightest  hint  that  it  was  either  unusual  or  perilous. 
Of  course,  as  soon  as  I  made  this  discovery  I  had  the 
patient  removed  to  another  room,  when  her  symp- 
toms soon  abated. 

I  could  easily  go  on  multiplying  examples  of  this 
kind,  but  I  shall  content  myself  with  one  more  case, 
which  was  thoroughly  worked  out,  with  very  in- 
structive results.  It  was  that  of  a  lady  who  was 
confined  of  her  first  child,  in  the  country  in  a  large 
and  expensive  house,  newly  built,  and  supposed  to 
be  supplied  with  all  the  most  perfected  sanitary 
arrangements.  There  was  nothing  particular  about 
the  labor,  and  for  the  first  ten  days  the  convalescence 
left  nothing  to  be  desired.  On  the  eleventh  day  she 
got  up  and  lay  on  the  sofa  (Fig.  208,  D)  opposite  the 
lire  (F),  which,  as  it  was  in  January,  was  burning 
day  and  night.  The  day  after,  although  she  had  a 
headache  and  felt  poorly,  she  again  got  up  and  lay 
on  the  sofa.  The  subsequent  day,  although  feeling 
very  ill,  she  again  insisted  on  getting  up,  and  lay 
on  the  sofa  at  E,  in  her  husband's  dressing-room. 
On  the  following  day  she  was  very  ill  indeed,  with 
a  temperature  of  104°  and  a  pulse  of  130,  and  I  was 
summoned  to  see  her.  It  is  needless  to  say  more  of 
her  illness,  which  rapidly  increased,  except  that, 
feeling  satisfied  it  was  caused  by  defective  sanita- 
tion, I  advised  her  removal  to  a  house  in  the  neigh- 
borhood, in  spite  of  the  verv  grave  symptoms  that 
existed,  with  the  most  satisfactory  result,  for  within 
twenty-four  hours  her  temperature  had  fallen,  and 
she  rapidly  became  convalescent.  Of  course,  at  this 
time  nothing  was  known  of  what  actually  existed, 
but  I  was  led  to  form  this  conclusion  from  the  fact  that  a  number  of  the  servants  and  residents  were 
suffering  from  sore-throats,  and  from  being  told  that  almost  everyone  who  came  to  stay  felt  ill  and 
out  of  sorts.  Subsequently  the  sanitary  state  of  the  house  was  thoroughly  investigated  by  one  of  the 
most  distinguished  sanitary  engineers  in  London,  from  whose  reports  the  accompanying  diagram 
(Fig.  208)  is  copied.  It  is  useless  to  enter  into  n  description  of  all  the  abominations  which  were 
found  to  exist,  which,  in  a  house  of  the  kind,  in  the  building  of  which  no  expense  was  spared, 
were  almost  past  belief.  For  the  purpose  of  my  story  it  will  suffice  to  say  that  the  smoke  test 
showed  that  there  was  a  very  abundant  escape  of  sewer-gas  in  both  the  bedroom  and  dressing- 
room,  which,  from  the  fact  that  there  were  large  fires  burning  constantly  In  both  rooms,  passed 
in  a  continuous  current  in  the  direction  of  the  arrows.  In  addition,  the  plumbing-work  in  the 
closet,  B,  in  the  dressing-room,  had  been  so  imperfectly  done  that  its  contents  found  their  way  out 
under  the  floor,  E.  Now,  mark  how  thoroughly  and  "curiously  these  facts  prove  the  cause  of  the 
disease.  The  patient  lay  in  the  bed  at  c,  which,  from  the  accident  of  its  being  winter,  and  the 


B 


BED     ROOM 


PUEEPERAL    SEPTICAEMIA. 


635 


of  the  disease  was  clearly  pointed  out  by  Gordon l  toward  the  end  of 
last  century,  who  stated  that  he  himself  "  was  the  means  of  carrying 
the  infection  to  a  great  number  of  women,"  and  he  also  traced  the 
spread  of  the  disease  in  the  same  way  in  the  practice  of  certain  mid- 
wives.  In  some  remarkable  instances  the  unhappy  property  of  carry- 
ing contagion  has  clung  to  individuals  in  a  way  which  is  most 
mysterious,  and  which  has  led  to  the  supposition  that  the  whole  system 
becomes  saturated  with  the  poison.  One  of  the  strangest  cases  of  this 
kind  was  that  of  the  late  Dr.  Rutter,  of  Philadelphia,  which  caused 
much  discussion.  He  had  forty-five  cases  of  puerperal  septicaemia  in 
his  own  practice  in  one  year,  while  none  of  his  neighbors'  patients  wrere 
attacked.  Of  him  it  is  related  :  "  Dr.  Rutter,  to  rid  himself  of  the 
mysterious  influence  which  seemed  to  attend  upon  his  practice,  left  the 
city  for  ten  days,  and  before  waiting  on  the  next  parturient  case  had 
his  hair  shaved  off  and  put  on  a  wig,  took  a  hot  bath,  and  changed 
every  article  of  his  apparel,  taking  nothing  with  him  that  he  had  worn 

current  of  sewer-gas  being  drawn  therefore  to  the  chimneys,  was  quite  out  of  its  reach,  and  for 
the  first  ten  days  after  her  confinement,  while  she  remained  in  bed,  she  was  perfectly  well.  On 
the  eleventh  day,  when  she  got  up,  she  was  placed  directly  in  the  current  of  sewer-gas  at  n,  and 
instantly  got  poisoned.  On  the  twelfth  and  thirteenth  days  she  was  again  exposed  to  the  absorp- 
tion of  further  and  more  intense  poisoning,  at  E  ;  while  immediately  on  her  removal  to  fresh  and 

FIG.  208. 


uncontaminated  air  all  her  threatening  symptoms  disappeared.  Remark  also  that  there  was 
nothing  peculiar  in  the  symptomatology,  nothing  different  from  an  ordinary  and  rapidly  progress- 
ing case  of  puerperal  septicfEmia.  It  seems  to  me  that  this  instructive  history  is  about  as  complete 
a  demonstration  of  the  origin  of  puerperal  disease  from  defective  sanitation  as  anyone  could  pos- 
eibly  desire,  and  I  can  see  no  flaw  in  the  chain  of  evidence. 
1  See  Lectures  on  Puerperal  Fever.  By  Robert  J.  Lee,  M.D. 


636  THE    PUERPERAL    STATE. 

or  carried,  to  his  knowledge,  on  any  former  occasion  :  and  mark  the 
result.  The  lady,  notwithstanding  that  she  had  an  easy  parturition, 
was  seized  the  next  day  with  childbed  fever,  and  died  on  the  eleventh 
day  after  the  birth  of  the  child.  Two  years  later  he  made  another 
attempt  at  self-purification,  and  the  next  case  attended  fell  a  victim  to 
the  same  disease."  Xo  wonder  that  the  late  Charles  D.  Meigs,  in 
commenting  on  such  a  history,  refused  to  believe  that  the  doctor  car- 
ried the  poison,  and  rather  thought  "  that  he  was  merely  unhappy  in 
meeting  with  such  accidents  through  God's  providence."  It  appears, 
however,  that  Dr.  Ilutter  was  the  subject  of  a  form  of  ozsena,  and  it  is 
quite  obvious  that,  under  such  circumstances,  his  hands  could  never 
have  been  free  from  septic  matter.1  This  observation  is  of  peculiar 
interest  as  showing  that  the  sources  of  infection  may  exist  in  conditions 
difficult  to  suspect  and  impossible  to  obviate,  and  it  affords  a  satis- 
factory explanation  of  a  case  which  was  for  years  considered  puzzling 
in  the  extreme.  It  is  quite  possible  that  other  similar  cases,  of  which 
many  are  on  record,  although  none  so  remarkable,  may  possibly  have 
depended  on  some  similar  cause  personal  to  the  medical  attendant. 

Proby2  suggests  that  a  similar  source  of  infection  may  occasionally 
be  found  in  a  carious  tooth  or  alveolar  abscess,  the  pus  infecting  the 
examining  finger. 

The  sources  of  septic  poison  being  thus  multifarious,  a  few  words 
may  be  said  here  as  to  the  mode  in  which  it  may  be  conveyed  to  the 
patient. 

Mode  in  •which  the  Poison  may  be  Conveyed  to  the  Patient. — 
As  on  the  view  of  puerperal  septicaemia  which  seems  most  to  agree 
with  recorded  facts,  the  poison,  from  whatever  source  it  may  be  derived, 
must  come  into  actual  contact  with  lesions  of  continuity  in  the  genera- 
tive tract,  it  is  obvious  that  one  method  of  conveyance  may  be  on  the 
hands  of  the  accoucheur.  That  this  is  a  possibility,  and  that  the  dis- 
ease has  often  been  unhappily  conveyed  in  this  way,  no  one  can  doubt. 
Still  it  would  be  unfair  in  the  extreme  to  conclude  that  this  is  the  only 
way  in  which  infection  may  arise.  In  town  practice,  especially,  there 
are  many  other  ways  in  which  septic  matter  may  reach  the  patient. 
The  nurse  may  be  the  means  of  communication,  and  if  she  has  been  in 
contact  with  septic  matter  she  is  even  more  likely  than  the  medical 
attendant  to  convey  it  when  washing  the  genitals  during  the  first  few 
days  after  {lelivery,  the  time  at  which  absorption  is  most  apt  to  occur. 
Barnes  relates  a  whole  series  of  cases  occurring  in  a  suburb  of  London, 
in  the  practice  of  different  practitioners,  every  one  of  which  was 
attended  by  the  same  nurse.  Again,  septic  matter  may  be  carried  in 
sponges,  linen,  and  other  articles.  What  is  more  likely,  for  example, 
than  that  a  careless  nurse  might  use  an  imperfectly  washed  sponge,  on 
which  discharge  has  been  allowed  to  remain  and  decompose?  Nor  do 

i  This  is  stated  on  the  authority  of  an  obstetrical  contemporary  of  Dr.  Rutter.  See  Amer.  Journ. 
of  Med.  Sciences.  1875,  vol.  Ixix.  p.  474.  (Minor.) 

The  author  quotes  from  the  editor.  Dr.  Rutter  had  an  ozaena  which  in  time  much  disfigured 
him  from  its  effect  upon  the  contour  of  his  nose.  He  was  unfortunately  inoculated  iu  his  index 
finger  from  a  patient,  and  neglected  the  pustule.  He  had  ninety-five  cases  of  puerperal  septicsemia 
in  four  years  and  nine  months,  with  eighteen  deaths.  The  question  of  Dr.  Meigs,  who  was  a  non- 
contagionist  in  regard  to  puerperal  peritonitis,  was  remarkably  apposite  :  "  Did  he  distil  a  subtle 
essence  which  he  carried  with  him?"— Harris's  note  to  the  third  American  edition. 

*  Lancet,  December  21, 1889. 


PUERPERAL    SEPTICAEMIA.  637 

I  see  any  reason  to  question  the  possibility  of  infection  from  septic 
matter  suspended  in  the  atmosphere ;  and  in  lying-in  hospitals,  where 
many  women  are  congregated  together,  there  can  be  little  doubt  that 
this  is  a  common  origin  of  the  disease.  It  is  certain,  whatever  view 
we  may  take  of  the  character  of  the  septic  material,  that  it  must  be  in 
a  state  of  very  minute  subdivision,  and  there  is  no  theoretical  difficulty 
in  the  assumption  of  its  being  conveyed  by  the  atmosphere. 

Conduct  of  the  Practitioner  in  Relation  to  the  Disease. — This 
question  naturally  involves  a  reference  to  the  duty  of  those  who  are 
unfortunately  brought  into  contact  with  septic  matter  in  any  form, 
either  in  a  patient  suffering  from  puerperal  septicasmia,  zymotic  dis- 
ease, or  offensive  discharges.  The  practitioner  cannot  always  avoid 
such  contact,  and  it  is  practically  impossible  to  relinquish  obstetric 
work  every  time  that  he  is  in  attendance  on  a  case  from  which  con- 
tagio"n  may  be  carried.  Nor  do  I  believe,  especially  in  these  days 
when  the  use  of  antiseptics  is  so  well  understood,  that  it  is  essential. 
It  was  otherwise  when  antiseptics  were  not  employed ;  but  I  can 
scarcely  conceive  any  case  in  which  the  risk  of  infection  cannot  be 
prevented  by  proper  care.  The  danger  I  believe  to  be  chiefly  in  not 
recognizing  the  possible  risk,  and  in  neglecting  the  use  of  proper  pre- 
cautions. It  is  impossible,  therefore,  to  urge  too  strongly  the  necessity 
of  extreme  and  even  exaggerated  care  in  this  direction.  The  prac- 
titioner should  accustom  himself,  as  much  as  possible,  to  use  the  left 
hand  only  in  touching  patients  suffering  from  infectious  diseases,  as 
that  which  is  not  used,  under  ordinary  circumstances,  in  obstetric 
manipulations.  He  should  be  most  careful  in  the  frequent  employ- 
ment of  antiseptics  in  washing  his  hands,  such  as  the  1  : 1000  solution 
of  perchloride  of  mercury.  Clothing  should  be  changed  on  leaving  an 
infectious  case.  Much  more  care  than  is  usually  practised  should  be 
taken  by  nurses,  especially  in  securing  perfect  cleanliness  in  everything 
brought  into  contact  with  the  patient.  When,  however,  a  practitioner 
•is  in  actual  and  constant  attendance  on  a  case  of  puerperal  septicaemia, 
when  he  is  visiting  his  patient  many  times  a  day,  especially  if  he  be 
himself  washing  out  the  uterus  with  antiseptic  lotions,  it  is  certain  that 
he  cannot  deliver  other  patients  with  safety,  and  he  should  secure  the 
assistance  of  a  brother  practitioner,  although  there  seems  no  reason 
why  he  should  not  visit  women  already  confined,  in  whom  he  has  not 
to  make  vaginal  examinations. 

Prophylaxis  of  Septicaemia. — If  the  views  here  inculcated  as  to 
the  nature  and  the  mode  of  infection  in  puerperal  septicaemia  be  correct, 
it  is  obvious  that  much  may  be  done  in  the  way  of  prophylaxis.  A 
perfectly  aseptic  management  of  puerperal  women  is  practically  impos- 
sible. In  most  lying-in  institutions  very  rigid  rules  are  now  laid  down 
to  prevent  the  possibility  of  infective  matter  being  conveyed  to  the 
patient  either  on  the  hands  of  the  attendants,  or  on  instruments, 
napkins,  and  the  like,  and  with  the  most  satisfactory  results.  As  the 
risk  is  much  greater  when  lying-in  women  are  collected  together,  such 
precautions,  which  this  is  not  the  place  to  discuss,  are  absolutely  indi- 
cated. They  are  not,  however,  easily  applicable  in  ordinary  private 
practice;  but  there  are  certain  simple  precautions  which  everyone 


638  THE    PUERPERAL    STATE. 

might  adopt  without  trouble,  which  will  materially  lessen  the  risk  of 
septic  poisoning.  Among  these  may  be  indicated  the  use  of  antiseptic 
lotions,  with  which  the  practitioner  and  nurse  should  always  wash  their 
hands  before  attending  any  case  or  touching  the  genital  organs ;  the  use 
of  carbolized  vaseline,  1  :  8,  for  lubricating  the  fingers,  catheter,  for- 
ceps, etc. ;  syringing  out  the  vagina  night  and  morning  with  creolin 
and  water  ;  rigid  attention  to  cleanliness  in  bedding,  napkins,  etc. 
Precautions  such  as  these,  although  they  may  appear  to  some  frivolous 
and  useless,  indicate  a  recognition  of  danger  and  an  endeavor  to  remove 
it,  and  if  they  were  generally  inculcated  on  nurses  (see  note,  p.  584) 
and  others,  might  go  far  to  prevent  the  occurrence  of  septic  mischief. 

Nature  of  the  Septic  Poison. — As  to  the  precise  character  of  the 
septic  poison — although  of  late  much  has  been  said  about  it,  and  there 
is  good  reason  to  believe  that  further  research  may  throw  light  on  this 
obscure  subject — too  little  is  known  to  justify  any  positive  statement. 
The  researches  of  Heiberg,  Von  Recklinghausen,  Steurer,  and  others 
have  shown  that  in  puerperal  septicaemia,  as  in  surgical  fever,  erysipelas, 
and  other  infectious  diseases,  micrococci  in  large  numbers  may  be  traced 
passing  between  the  muscular  and  connective-tissue  fibres,  through  the 
lymphatics,  and  thus  into  the  general  circulation,  and  that  they  may  be 
found  in  various  organs  and  pathological  products.  More  recently 
Frankel  isolated  from  a  number  of  cases  a  chain-forming  micrococcus, 
which  he  at  first  regarded  as  specific,  and  named  the  streptococcus 
puerperalis.  Subsequently  he  satisfied  himself  of  its  identity  with  a 
similar  micro-organism  in  pus.  Winckel  also  cultivated  a  streptococcus 
from  a  case  of  puerperal  peritonitis.  It  produced  an  erysipelatous 
rash  in  the  ear  of  a  rabbit,  and  was  similar  in  its  characters,  both  mor- 
phologically and  in  artificial  cultivations,  to  the  streptococcus  found  in 
erysipelas.  Gushing  found  streptococci  in  eudometritis  diphtheritica 
and  in  secondary  puerperal  inflammation,  and  Baumgarten,  Bumrn, 
Pfannestiel,  and  others  have  recorded  similar  observations.  Pfanne- 
stiel  investigated  four  cases  of  puerperal  septicaemia  with  diphtheritic 
endometritis  and  purulent  peritonitis,  and  he  concluded  that  a  specific 
micro-organism  could  not  be  differentiated  in  puerperal  fever.  In  his 
opinion  the  streptococci  from  pus,  from  erysipelas,  and  diphtheritic 
affections  of  the  pharynx  had  all  the  power  of  setting  up  puerperal 
septicaemia.  Doleris  never  failed  to  find  streptococci  in  the  blood  in 
puerperal  septicaemia,  and  after  death  they  are  readily  detected  in  great 
numbers.  They  do  not  multiply  in  the  blood  during  life,  but  they 
cause  changes  in-  both  the  red  and  white  corpuscles,  which  stick 
together  and  form  minute  capillary  infarctions,  in  which  the  micrococci 
increase,  and  from  which  they  invade  the  surrounding  structures  and 
produce  various  pathological  changes.  These  observations  are  of  much 
importance,  as  tending  to  confirm  by  scientific  observation  the  intimate 
relation  between  these  various  forms  of  disease  which  has  long  been 
believed  to  exist.  It  may  be  taken  as  certain  that  streptococci  bear  an 
intimate  and  important  relation  to  the  disease ;  but  whether  they  them- 
selves form  the  septic  matter  or  carry  it,  or  whether  they  are  mere 
accidental  concomitants  of  the  pysemic  processes,  it  is  impossible,  in 
the  present  state  of  our  knowledge,  to  decide. 


PUERPERAL    SEPTICAEMIA.  639 

Channels  of  Diffusion. — Passing  on  to  the  channels  of  diffusion 
through  which  the  septic  matter  may  act,  we  have  to  consider  its  effects 
on  the  structures  with  which  it  is  brought  into  contact,  and  the  mode 
in  which  it  may  infect  the  system  at  large ;  and  this  will  include  a 
consideration  of  the  pathological  phenomena. 

Local  changes  consequent  on  the  absorption  of  the  poison  are 
pretty  constant,  and  of  these  we  may  form  an  intelligent  idea  by 
thinking  of  them  as  similar  in  character  and  causation  to  those  which 
we  have  the  opportunity  of  studying  when  septic  matter  is  applied  to 
a  wound  open  to  observation,  as,  for  example,  in  cases  of  blood- 
poisoning  following  a  dissection  wound.  Distinct  traces  of  local  action 
are  not  of  invariable  occurrence,  and  in  some  of  the  worst  class  of 
cases,  when  the  amount  of  septic  matter  is  great  and  "its  absorption 
rapid,  death  may  occur  after  an  illness  of  short  duration  but  great 
intensity,  and  before  appreciable  local  changes,  either  at  the  site  of 
absorption  or  in  the  system  at  large,  have  had  time  to  develop  them- 
selves. The  fact  that  puerperal  fever  may  prove  fatal,  without  leaving 
any  tangible  post-mortem  signs,  has  often  been  pointed  out,  such  cases 
most  frequently  occurring  during  the  endemic  prevalence  of  the  disease 
in  lying-in  hospitals.  There  can  be  little  doubt,  however,  that  in  such 
cases  of  intense  septicaemia  marked  pathological  changes  exist  in  the 
form  of  alterations  of  the  blood  and  degenerations  of  tissue,  but  not 
of  a  character  which  can  be  detected  by  an  ordinary  post-mortem 
examination.  In  the  great  majority  of  cases,  indications  of  the  disease 
exist  at  the  site  of  absorption.  These  are  described  by  pathologists  as 
identical  in  their  character  with  the  inflammatory  oedema  which  occurs 
in  connection  with  phlegmonous  erysipelas.  If  lacerations  exist  in 
the  cervix  or  vagina,  they  take  on  unhealthy  action,  their  edges 
swell,  and  their  surfaces  become  covered  with  a  yellowish  coat,  similar 
in  appearance  to  diphtheritic  membrane.  The  mucous  membrane  of 
the  uterus  is  also  generally  found  to  be  affected,  and  in  a  degree  vary- 
ing with  the  intensity  of  the  local  septic  process.  There  is  evidence 
of  severe  endometritis  ;  and,  very  frequently,  the  whole  lining  of  the 
uterus  is  profoundly  altered,  softened,  covered  with  patches  of  diph- 
theritic deposit,  and  it  may  be  in  a  state  of  general  necrosis.  In  the 
severer  cases  these  changes  affect  the  muscular  tissue  of  the  uterus, 
which  is  found  to  be  swollen,  soft,  imperfectly  contracted,  and  even 
partially  necrosed,  #  condition  which  is  likened  by  Heiberg  to  hospital 
gangrene.  The  connective  tissue  surrounding  the  generative  tract  is 
also  swollen  and  oedematous,  and  the  inflammation  may  in  this  way 
reach  the  peritoneum,  although  peritonitis,  so  often  observed  in  puer- 
peral septicaemia  does  not  necessarily  depend  on  the  direct  transmission 
of  inflammation  from  the  pelvic  connective  tissue,  but  is  more  often  a 
secondary  phenomenon. 

The  channels  through  which  general  systemic  infection  may 
supervene  are  the  lymphatics  and  the  venous  sinuses,  the  former 
being  by  far  the  most  important.  Recent  researches  have  shown  the 
great  number  and  complexity  of  the  lymphatics  in  connection  with  the 
pelvic  viscera,  and  marked  traces  of  the  absorption  of  septic  matter  are 
almost  always  to  be  found,  except  in  those  very  intense  cases  already 


640  THE    PUERPERAL    STATE. 

alluded  to,  in  which  no  appreciable  post-mortem  signs  are  discover- 
able. The  septic  matter  is  probably  absorbed  from  the  lymph  spaces 
abounding  in  the  connective  tissue,  and  carried  along  the  lymphatic 
canals  to  the  nearest  glands.  The  result  is  inflammation  of  their 
coats,  and  thrombosis  of  their  contents,  which  may  be  seen  on  section 
as  a  creamy,  purulent  substance.  The  absorption  of  septic  material 
may,  as  Virchow  has  shown,  be  delayed  by  the  local  changes  produced 
in  the  lymphatics  and  in  the  glands  with  which  they  communicate, 
which  are,  therefore,  conservative  in  their  action ;  and  the  further 
progress  of  the  case  may  in  this  way  be  stopped  and  local  inflamma- 
tion alone  result,  such  cases  being  believed  by  Heiberg  to  be  examples 
of  abortive  pyaemia.  On  the  other  hand,  the  free  septic  material  may 
be  too  abundant  and  intense  to  be  so  arrested,  it  may  pass  on  through 
the  lymph  canals  and  glands,  until  it  reaches  the  blood-current 
through  the  thoracic  duct,  and  so  produces  a  general  blood-infection. 
This  mode  of  absorption  of  septic  matter,  and  the  tendency  of  the 
glands  to  arrest  its  further  progress,  serve  to  explain  the  progressive 
character  of  many  cases,  in  which  fresh  exacerbations  seem  to  occur  from 
time  to  time  ;  since  fresh  quantities  of  poison,  generated  at  its  source  of 
origin,  may  be  absorbed  as  the  case  progresses.  The  uterine  veins  are 
supposed  by  D'Espine  to  be  the  channel  of  absorption  in  the  intense 
form  of  disease  which  proves  fatal  very  shortly  after  delivery,  too  soon 
for  the  more  gradual  process  of  lymphatic  absorption  to  have  become 
established.  It  is  evident  that  the  veins  are  not  likely  to  act  in  this 
way,  since  they  must,  under  ordinary  circumstances,  be  completely 
occluded  by  thrombi,  otherwise  hemorrhage  would  occur.  If,  however, 
uterine  contraction  be  incomplete,  the  occlusion  of  the  venous  sinuses 
may  be  imperfect,  and  absorption  of  septic  material  through  them  may 
then  take  place.  Some  writers  have  laid  great  stress  on  imperfect 
uterine  contraction  in  predisposing  to  septicaemia,  and  its  influence 
may  thus  be  well  explained.  The  veins  may  bear  an  important  part 
in  the  production  of  septicaemia,  independent  of  the  direct  absorption 
of  septic  matter  through  them,  by  means  of  the  detachment  of  minute 
portions  of  their  occluding  thrombi,  in  the  form  of  emboli.  If  phleg- 
monous  inflammation  occurs  in  the  immediate  vicinity  of  the  veins,  the 
thrombi  they  contain  may  become  infected.  When  once  blood-infec- 
tion has  occurred  by  any  of  these  channels,  general  septicaemia,  the 
so-called  puerperal  fever,  is  developed. 

Four  Principal  Types  of  Pathological  Chang-e. — The  variety  of 
pathological  phenomena  found  on  post-mortem  examination  has  had 
much  to  do  with  the  prevalent  confusion  as  to  the  nature  of  the  disease. 
This  has  resulted  in  the  description  of  many  distinct  forms  of  puer- 
peral fever,  the  most  marked  pathological  alteration  having  been  taken 
to  be  the  essential  element  of  the  disease.  As  a  matter  of  fact,  there 
is  no  doubt  that  various  types  of  pathological  change  are  met  with. 
Heiberg  describes  four  chief  classes  which  are  by  no  means  distinctly 
separated,  are  often  found  simultaneously  in  the  same  subject,  and 
are  certainly  not  to  be  distinguished  by  the  symptoms  during  life. 

Of  these  the  first  is  the  class  of  cases  in  which  no  appreciable  morbid 
phenomena  are  found  after  death.  This  formidable  and  fatal  form  of 


PUERPERAL    SEPTICAEMIA.  641 

the  disease  has  long  been  well  known,  and  is  that  described  by  some 
of  our  authors  as  adynamic  or  malignant  puerperal  fever.  It  is  the 
variety  which  was  so  prevalent  in  our  lying-in  hospitals,  and  which 
Eamsbotham  talks  of  as  being  second  only  to  cholera  in  thb  severity 
and  suddenness  of  its  onset  and  in  the  rapidity  with  which  it  carried 
off  its  victims.  It  is  quite  erroneous  to  suppose  that  the  existence  of 
pathological  changes  in  this  form  of  disease  has  never  been  recognized. 
Even  with  the  coarse  methods  of  examination  formerly  used,  the 
occurrence  of  a  fluid  and  altered  state  of  the  blood,  and  ecchymoses 
in  connection  with  various  organs — especially  the  lungs,  spleen,  and 
kidneys — were  noticed  and  specially  described  by  Coupland  in  his 
Dictionary  of  Medicine.  More  recently  it  has  been  clearly  proved  by 
the  microscope  that  there  exist,  in  addition,  the  commencement  of 
inflammation  in  most  of  the  tissues,  shown  by  cloudy  swellings,  and 
granular  infiltration  and  disintegration  of  the  cell  elements ;  proving 
that  the  blood,  heavily  charged  with  septic  matter,  had  set  up  morbid 
action  wherever  it  circulated,  the  patient  succumbing  before  this  had 
time  to  develop. 

In  the  second  type,  and  that  perhaps  most  commonly  met  with,  the 
morbid  changes  are  more  frequently  found  in  the  serous  membranes, 
in  the  pleura,  in  the  pericardium,  but,  above  all,  in  the  peritoneum,  the 
alterations  in  which  have  long  attracted  notice  and  have  been  taken 
by  many  writers  as  proving  peritonitis  to  be  the  main  element  of  the 
disease.  Evidences  of  more  or  less  peritonitis  are  very  general.  In 
the  more  severe  cases  there  is  little  or  no  exudation  of  plastic  lymph, 
such  as  is  found  in  peritonitis  unassociated  with  septicaemia.  There 
is  a  greater  or  less  quantity  of  brownish  serum  only,  the  coils  of  in- 
testine, distended  with  flatus  and  highly  congested,  being  surrounded 
by  it.  More  often  there  are  patchy  deposits  of  fibrinous  exudation 
over  many  of  the  viscera,  the  fundus  uteri,  the  under  surface  of  the 
liver,  and  the  distended  intestines.  There  is  then,  also,  a  considerable 
quantity  of  sero-purulent  fluid  in  the  abdominal  cavity.  The  pleural 
cavities  may  also  exhibit  similar  traces  of  inflammatory  action,  con- 
taining imperfectly  organized  lymph  and  sero-purulent  fluid.  Schroeder 
states  that  pleurisy  is  more  often  the  direct  result  of  transmission  of 
inflammation  through  the  substance  of  the  diaphragm  or  lung  than  a 
secondary  consequence  of  the  septicaemia.  In  like  manner  evidences 
of  pericarditis  may  exist,  the  surface  of  the  pericardium  being  highly 
injected  and  its  cavity  containing  serous  fluid.  Inflammation  of  the 
synovial  membranes  of  the  larger  joints,  occasionally  ending  in  sup- 
puration, is  not  uncommon  and  may  probably  be  best  included  under 
this  class  of  cases. 

In  the  third  type  the  mucous  membranes  appear  to  bear  the  brunt 
of  the  disease.  The  pathological  changes  are  most  marked  in  the 
mucous  membrane  lining  the  intestines,  which  is  highly  congested  and 
even  ulcerated  in  patches,  with  numerous  small  spots  of  blood  ex- 
travasated  in  the  submucous  tissue.  Similar  small  apoplectic  effusions 
have  been  observed  in  the  substance  of  the  kidneys  and  under  the 
mucous  membrane  of  the  bladder.  Pneumonia  is  of  common  occur- 
rence. In  most  cases  it  is  probably  secondary  to  the  impaction  of 

41 


642 


THE    PUERPERAL    STATE. 


minute  emboli  in  the  smaller  branches  of  the  pulmonary  artery ;  but 
it  may  doubtless  arise  from  independent  inflammation  of  the  lung 
tissue,  and  will  then  be  included  in  a  class  of  cases  now  under  con- 
sideration. 

The  fourth  class  of  pathological  phenomena  are  those  which  are 
produced  chiefly  by  the  impaction  of  minute  infected  emboli  in  small 
vessels  in  various  parts  of  the  bod)-.  These  are  the  cases  which  most 
closely  resemble  surgical  pyaemia,  both  in  their  symptoms  and  post- 
mortem signs,  and  which  by  many  writers  are  described  under  the 

FIG.  209. 


TIME      MlE    MIE    M   E   M   E  M    E  M    E   M   E    M  £    M  E    M  E    M  E    M  E 


A.  S.,  aged  thirty  years;  confined  February  27, 1879;  died  March  10th. 

name  of  puerperal  pyaemia.  The  dependence  of  puerperal  fever  no 
phlebitis  of  the  uterine  veins  was  a  favorite  theory,  and  in  a  large 
proportion  of  cases  the  coats  of  the  veins  show  signs  of  inflammation, 
their  canals  being  occupied  with  thrombi  in  a  more  or  less  advanced 
state  of  disintegration.  The  mode  in  which  these  thrombi  may  become 
infected  has  been  shown  by  Babnoff,  who  has  proved  that  leucocytes 
may  penetrate  the  coats  of  the  vein,  and  entering  its  contained  coaguhim 
may  set  up  disintegration  and  suppuration.  This  observation  brings 
these  pyaemic  forms  of  disease  into  close  relation  with  septicaemia  such 
as  we  have  been  studying,  and  justifies  the  conclusion  of  Verneuil 
that  purulent  infection  is  not  a  distinct  disease,  but  only  a  termination 


PUERPERAL    SEPTICAEMIA. 


643 


of  septicaemia,  with  which  it  ought  to  be  studied.  We  have,  more- 
over, to  differentiate  these  results  of  embolism  from  those  considered 
in  a  subsequent  chapter,  the  characteristic  of  these  cases  being  the 
infected  nature  of  the  minute  eniboli.  Localized  inflammations  and 
abscesses,  from  the  impaction  of  minute  capillary  emboli,  are  found  in 
many  parts  of  the  body ;  most  frequently  in  the  lungs,  then  in  the 
kidneys,  spleen,  and  liver,  and  also  in  the  muscles  and  connective 
tissues.  Pathologists  are  by  no  means  agreed  as  to  the  invariable 
dependence  of  these  on  embolism,  nor  is  it  possible  to  prove  their 


TIME      M   E   M    E    M|£   MJE    M  EJMJE    MJElMIElMiE   M  I  E  L   E  I  M   E  |M;  E  I  M ;  E  I  M!  E 


Mrs.  D.,  aged  twenty-five  years;  confined  May  1,  1879.     Puerperal  septicaemia ;  recovery.    An 
untrapped  pipe,  communicating  with  sewer,  was  found  in  bath  close  to  this  patient's  bed. 

origin  from  this  source  by  post-mortem  examination.  Some  attribute 
all  such  cases  to  embolism,  others  think  that  they  may  be  the  results 
of  primary  septicsemic  inflammation.  It  has  been  proved  by  Weber 
that  minute  infected  emboli  may  pass  through  the  lung  capillaries ; 
and  this  disposes  of  one  argument  against  the  embolic  theory,  based 
on  the  supposed  impossibility  of  their  passage.  It  is  probable  that 
both  causes  may  operate,  and  that  localized  inflammations  occurring  a 
short  time  after  delivery  are  directly  produced  by  the  infected  blood, 
while  those  occurring  after  the  lapse  of  some  time,  as  in  the  second  or 
third  week,  depend  upon  embolism. 


644 


THE    PUERPERAL    STATE. 


cases. 


FIG.  211. 


Description  of  the  Disease. — From  what  has  been  said  as  to  the 
mode  of  infection  in  puerperal  septicaemia,  and  as  to  the  very  various 
pathological  changes  which  accompany  it,  it  will  not  be  a  matter  of 
surprise  to  find  that  the  symptoms  are  also  very  various  in  different 
This  can  readily  be  explained  by  the  amount  and  virulence  of 

the  poison  absorbed,  the  channels  of 
infection,  and  the  organs  which  are 
chiefly  implicated ;  but  it  renders  it 
very  difficult  to  describe  the  disease 
satisfactorily. 

The  symptoms  generally  show 
themselves  within  two  or  three  days 
after  delivery.  As  infection  most 
often  occurs  during  labor,  or  in  cases 
which  are  sapra3rnic  within  a  short 
time  afterward,  and  before  the  lesions 
of  continuity  in  the  generative  tract 
have  commenced  to  cicatrize,  it  can 
be  understood  why  septicaemia  rarely 
commences  later  than  the  fourth  or 
fifth  day. 

In  the  great  majority  of  cases  the 
disease  begins  insidiously.  There 
are,  generally,  some  chilliness  and 
rigor,  but  by  no  means  always,  and 
even  when  present  they  frequently 
escape  observation  or  are  referred  to 
some  transient  cause.  The  first  symp- 
tom which  excites  attention  is  a  rise 
in  the  pulse,  which  may  vary  from 
100  to  140  or  more,  according  to  the 
severity  of  the  attack ;  and  the  ther- 
mometer will  also  show  that  the  tem- 
perature is  raised  to  102°,  or,  in  bad 
cases,  even  to  104°  or  106°.  Still  it 
must  be  borne  in  mind  that  both  the 
pulse  and  temperature  may  be  in- 
creased in  the  puerperal  state  from  transient  causes,  and  do  not  of 
themselves  justify  the  diagnosis  of  septicaemia. 

In  the  more  intense  class  of  cases,  in  which  the  whole  system  seems 
overwhelmed  with  the  severity  of  the  attack,  the  disease  progresses 
with  great  rapidity,  and  often  without  any  appreciable  indication  of 
local  complication.  The  pulse  is  very  rapid,  small,  and  feeble,  varying 
from  120  to  140,  and  there  is  generally  a  temperature  of  103°  to  104°. 
In  the  worst  form  of  cases  the  temperature  is  steadily  high  without 
marked  remissions  (see  Figs.  209,  214,  and  215).  There  may  be  little 
or  no  pain,  or  there  may  be  slight  tenderness  on  pressure  over  the 
abdomen  or  uterus ;  and,  as  the  disease  progresses,  the  intestines  get 
largely  distended  with  flatus,  so  that  intense  tympanites  often  forms  a 
most  distressing  symptom.  The  countenance  is  sallow,  sunken,  and 


Mrs.  P.,  aged  twenty- four  years ;  labor 
natural ;  confined  May  22, 1880.  A  piece  of 
decomposed  membrane  the  size  of  hand 
washed  out  of  her  uterus  at  first  intra-uterine 
injection ;  rapid  recovery. 


PUERPERAL    SEPTIC^MIA. 


645 


has  a  very  anxious  expression.  As  a  rule,  intelligence  is  unimpaired, 
and  this  may  be  the  case  even  in  the  worst  forms  of  the  disease,  and 
up  to  the  period  of  death.  At  other  times  there  is  a  good  deal  of  low 
muttering  delirium,  which  often  occurs  at  night  alone,  and  alternates 
with  intervals  of  complete  consciousness,  but  is  occasionally  intensified 
for  a  short  time  into  a  more  acute  form.  Diarrhoea  and  vomiting  are  of 
very  frequent  occurrence ;  by  the  latter,  dark,  grumous,  coffee-ground 
substances  are  ejected.  The  diarrhoaa  is  occasionally  very  profuse  and 
uncontrollable ;  in  mild  cases  it  seems  to  relieve  the  severity  of  the 

FIG.  212. 


T>ME       M  E   MIE   MJE    M  E    MiE    M  E    M  E   M   E   U  E    M  E    M  E   M   E   M  E   M   E 


Mrs.  N.,  aged  twenty-two  years ;  confined  Thursday,  May  6, 1880.    Forceps.    Lochia  from  the  first 
offensive ;  a  small  piece  of  membrane  was  probably  left  in  utero. 

symptoms.  The  tongue  is  moist  and  loaded  with  sordes ;  but  some- 
times it  gets  dark  and  dry,  especially  toward  the  termination  of  the 
disease.  The  lochia  are  generally  suppressed  or  altered  in  character, 
and  sometimes  they  have  a  highly  offensive  odor,  especially  when  the 
disease  is  of  the  so-called  autogenetic  type.  The  breathing  is  hurried 
and  panting,  and  the  breath  itself  has  a  characteristic,  heavy,  sweetish 
odor.  The  secretion  of  milk  is  often,  but  not  always,  arrested. 

Duration. — With  more  or  less  of  these  symptoms  the  case  goes  on  ; 
and  when  it  ends  fatally  it  generally  does  so  within  a  week,  the  fatal 
termination  being  indicated  by  more  weakness,  rapid,  thread-like,  or 
intermittent  pulse,  marked  delirium,  great  tympanites,  and  sometimes 


646 


THE    PUERPERAL    STATE. 


a  sudden  fall  of  temperature,  until  at  last  the  patient  sinks  with  all  the 
symptoms  of  profound  exhaustion. 

In  milder  cases  similar  symptoms,  variously  modified  and  combined, 
are  present.  It  is  seldom  that  two  precisely  similar  cases  are  met  with  ; 
in  some  the  rapid,  weak  pulse  is  most  marked :  in  others  abdominal 
distention,  vomiting,  diarrhoea,  or  delirium. 

Local  complications  variously  modify  the  symptoms  and  course  of 
the  disease.  The  most  common  is  peritonitis,  so  much  so  that  with 
some  authors  puerperal  fever  and  puerperal  peritonitis  are  synonymous 


FIG.  213. 


DATE    1  26   [  27  I  28  I  29   |  30  |  31   |Augl|   2 


Mrs.  -  ,  aged  twenty-five  years;  recovery.    Confined  July  26,  1879.  7.40  P.M. 

terms.  Here  the  first  symptom  is  severe  abdominal  pain,  commencing 
at  the  lower  part  of  the  abdomen,  where  the  uterus  is  felt  enlarged  and 
tender.  As  the  abdominal  pain  and  tenderness  spread,  the  sufferings  of 
the  patient  greatly  increase,  the  intestines  become  enormously  distended 
with  flatus,  and  the  breathing  is  entirely  thoracic,  in  consequence  of 
the  upward  displacement  of  the  diaphragm  and  the  fact  that  the 
abdominal  muscles  are  instinctively  kept  as  much  in  repose  as  possible. 
The  patient  lies  on  her  back  with  her  knees  drawn  up  and  sometimes 
cannot  bear  the  slightest  pressure  of  the  bedclothes.  There  is  gener- 
ally much  vomiting,  and  often  severe  diarrhoea.  The  temperature 
generally  ranges  from  102°  to  104°,  or  even  106°,  and  is  subject  to 


PUERPERAL    SEPTICAEMIA. 


647 


occasional  exacerbations  and  remissions,  possibly  depending  on  fresh 
absorption  of  septic  matter  (see  Figs.  210,  212,  and  213).  The  case 
generally  lasts  for  a  week  or  more,  the  symptoms  going  on  from  bad 
to  worse,  and  the  patient  dying  exhausted.  D'Espine  points  out  that 
rigors,  with  exacerbations  of  the  general  symptoms,  not  unfrequently 
occur  about  the  sixth  or  seventh  day,  which  he  attributes  to  fresh 
systemic  infection  from  fetid  pus  in  the  peritoneal  cavity.  It  must 
not  be  supposed  that  all  these  symptoms  are  necessarily  present  when 
the  peritonitic  complication  exists.  Pain  is  especially  often  entirely 
absent,  and  I  have  seen  cases  in  which  post-mortem  examination 


FIG.  214. 


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Mrs.  M.  K.,  aged  twenty-one  years ;  infection  believed  to  be  due  to  scarlatina. 
Confined  August  5, 1878 ;  recovery. 

proved  the  existence  of  peritonitis  in  a  very  marked  degree,  in  which 
pain  was  entirely  absent.  Sometimes  the  pain  is  only  slight  and 
amounts  to  little  more  than  tenderness  over  the  uterus. 

Symptoms  of  other  local  complications  are  characterized  by  their 
own  special  symptoms:  thus,  pneumonia  by  dyspnoea,  cough,  dulness, 
etc.;  pericarditis  by  the  characteristic  rub;  pleurisy  by  dulness  on  per- 
cussion; kidney  affection  by  albuminuria  and  the  presence  of  casts; 
liver  complication  by  jaundice;  and  so  on. 

Pysemic  Forms  of  the  Disease. — The  course  of  the  disease  is  not 
always  so  intense  and  rapid,  being  in  some  cases  of  a  more  chronio 
character  and  lasting  many  weeks.  The  symptoms  in  the  early  stage 


648  THE    PUERPERAL    STATE. 

are  often  indistinguishable  from  those  already  described,  and  it  is 
generally  only  after  the  second  week  that  indications  of  purulent  infec- 
tion develop  themselves.  Then  we  often  have  recurrent  and  very 
severe  rigors,  with  marked  elevations  and  remissions  of  temperature. 
At  the  same  time  there  is  generally  an  exacerbation  of  the  general 
symptoms,  peculiar  yellowish  discoloration  of  the  skin,  and  occasionally 
well-developed  jaundice.  Transient  patches  of  erythema  are  not  un- 
commonly observed  on  various  parts  of  the  skin,  and  such  eruptions 
have  often  been  mistaken  for  those  of  scarlet  fever  or  other  zymotic 
disease.  Localized  inflammations  and  suppuration  may  rapidly  follow. 
Amongst  the  most  common  are  inflammation  or  even  suppuration  of 
the  joints — the  knees,  shoulders,  or  hips — which  is  preceded  by  diffi- 
culty of  movement,  swelling,  and  very  acute  pain.  Large  collections 
of  pus  in  various  parts  of  the  muscles  and  connective  tissues  are  not 
rare.  Suppurative  inflammation  may  also  be  found  in  connection 
with  many  organs,  as  in  the  eye,  in  the  pleura,  pericardium,  or  lungs ; 
each  of  which  will,  of  course,  give  rise  to  characteristic  symptoms, 
more  or  less  modified  by  the  type  of  the  disease  and  the  intensity  of 
the  inflammation. 

Puerperal  Malarial  Fever. — There  is  a  peculiar  form  of  febrile 
disturbance  which  sometimes  occurs  in  the  puerperal  state,  and  which 
is  apt  to  be  confounded  with  septicaemia,  to  which  attention  was 
specially  directed  by  the  late  Fordyce  Barker,1  under  the  name  of 
"  puerperal  malarial  fever,"  It  is  specially  apt  to  be  met  with  in 
women  who  have  been  exposed  to  malarial  poison  during  their  former 
lives,  the  recurrence  of  the  fever  being  probably  determined  by  the 
puerperal  state.  Of  this  I  have  seen  several  very  well-marked  ex- 
amples in  ladies  who  had  formerly  contracted  fever  and  ague  in  India. 
One  of  my  patients  who  has  been  long  in  India,  and  suffered  from 
intermittent  fever  for  years,  is  invariably  attacked  with  it  after 
delivery,  and  herself  warned  me  of  the  fact  the  first  time  I  attended 
her.  The  diagnosis  is  not  always  easy.  Barker  insisted  on  the  fact 
that  puerperal  malarial  fever  generally  commences  after  the  fifth  day 
of  delivery,  while  septicaemia  almost  always  does  so  before  that  time. 
In  the  malarial  fever,  moreover,  the  intermissions  are  much  more 
marked,  while  there  are  frequently  recurring  chills  or  rigors,  which  is 
not  the  case  in  septicaBinia.' 

Treatment. — In  considering  the  all-important  subject  of  treatment, 
the  views  of  the  practitioner  are  naturally  biased  by  the  theory  he  has 
adopted  of  the  nature  of  the  disease.  If  that  here  inculcated  be  cor- 
rect, the  indications  we  have  to  bear  in  mind  are :  first,  to  discover,  if 
possible,  the  source  of  the  poison,  in  the  hope  of  arresting  further  septic 
absorption ;  secondly,  to  keep  the  patient  alive  until  the  effects  of  the 
poison  are  worn  off;  and  thirdly,  to  treat  any  local  complication  that 
may  arise. 

The  first  is  likely  to  be  of  great  importance  in  cases  of  saprsemia,  as 
fresh  quantities  of  septic  matter  may  be  from  time  to  time  absorbed. 
We,  fortunately,  are  in  possession  of  a  powerful  means  of  preventing 

i  "Puerperal  Malarial  Fever,"  Amer.  Journ.  of  Obstet.,  1880,  vol.  xiii.  p.  271. 


PUERPERAL    SEPTICAEMIA. 


649 


further  absorption  by  the  application  of  antiseptics  to  the  interior  of 
the  uterus  and  to  the  canal  of  the  vagina.  This  is  especially  valuable 
when  the  existence  of  decomposing  coagula  or  other  sources  of  septic 
matter  is  suspected  in  the  uterine  cavity,  or  when  offensive  discharges 


FIG  215. 


job 


105 


104 


103 


99 


30 


ill 


Ami 


Mrs.  B.,  aged  twenty-nine  years ;  confined  March  29  ;  died  April  7, 1879. 

are  present.  Disinfection  is  readily  accomplished  by  washing  out  the 
uterine  cavity,  at  least  twice  daily,  by  means  of  a  Higginson  syringe 
with  a  long  vaginal  pipe  attached.1  The  results  are  sometimes  very 
remarkable,  the  threatening  symptoms  rapidly  disappearing  and  the 
temperature  and  pulse  falling  so  soon  after  the  use  of  the  antiseptic 

i  My  colleague  Dr.  Hayes,  has  invented  a  silver  tube  for  the  purpose  of  administering  such  intra- 
uterine  injections  (Fig.  216),  which  answers  its  purpose  admirably.    The  numerous  apertures  at  il 

FIG.  216. 


Hayes's  tube  for  intra-uterme  injections. 


extremity  allow  of  a  number  of  minute  streams  of  fluid  being  thrown  out  in  the  form  of  a  spray 
over  the  interior  of  the  uterus,  the  complete  bathing  of  its  surface  and  wash.ng  out  of  il 
being  thus  insured.    It  is,  moreover,  introduced  more  easily  than  the  ordinary  vaginal  pipe,  an 
can  be  attached  to  a  Higginson  syringe. 


650 


THE    PUERPERAL    STATE. 


injections  as  to  leave  no  doubt  of  the  beneficial  effects  of  the  treatment. 
I  cannot  better  illustrate  the  advantages  of  this  treatment  than  by  the 
temperature  chart  (Fig.  217),  which  is  from  a  case  which  came  under 
my  observation  in  the  outdoor  practice  of  King's  College  Hospital. 
It  was  that  of  a  healthy  woman,  thirty-six  years  of  age,  who  had  an 
easy  and  natural  labor.  Nothing  remarkable  was  observed  until 
the  third  day  after  delivery,  when  the  temperature  was  found  to  be 
slightly  increased.  On  the  morning  of  the  eighth  day  the  temperature 
had  risen  to  105.8°.  She  was  delirious,  with  a  rapid,  thready  pulse, 

FIG.  217. 


clammy  perspiration,  tympanitic  abdomen,  and  her  general  condition 
indicated  the  most  urgent  danger.  ;  On  vaginal  examination  a  piece  of 
compressed  and  putrid  placenta  was  found  in  the  os.  This  was 
removed  by  my  colleague,  Dr.  Hayes,  and  the  uterus  thoroughly 
washed  out  with  Condy's  fluid  and  water.  The  same  evening  the 
temperature  had  sunk  to  99°  and  the  general  symptoms  were  much 
improved.  The  next  day  there  was  a  slight  return  of  offensive  dis- 
charge, and  an  aggravation  of  the  symptoms.  After  again  washing 
out  the  uterus  the  temperature  fell,  and  from  that  date  the  patient  con- 
valesced without  a  single  bad  symptom.  (See  Fig.  211.) 

This  is  a  very  well  marked  example  of  the  value  of  local  antiseptic 
treatment,  and  I  have  seen  many  cases  of  the  same  kind.  It  should, 
therefore,  never  be  omitted  in  all  cases  in  which  the  presence  of  decom- 
posing structures  within  the  uterus  is  suspected ;  and,  indeed,  even 
when  there  is  no  reason  to  suspect  the  presence  of  a  local  focus  of 
infection,  the  use  of  antiseptic  lotions  is  advisable  as  a  matter  of  pre- 
caution, since  it  can  do  no  harm  and  is  generally  comforting  to  the 
patient.  Various  antiseptics  may  be  used,  such  as  a  weak  solution  of 
carbolic  acid,  1  :  50,  tincture  of  iodine  dropped  into  warm  water  until 
it  has  a  pale  sherry  color,  or  a  solution  of  perchloride  of  mercury  of 
the  strength  of  1  :  2000.  Of  these,  the  perchloride  of  mercury  solution 
is  the  most  effective  germicide,  and  Koch's  experiments  have  conclu- 
sively proved  that  it  is  the  only  recognized  antiseptic  which  can  be 
relied  upon  for  destroying  the  spores  of  micro-organisms  after  a  single 
application.  As,  however,  there  is  a  possibility  that  a  too  free  and 
incautious  use  of  the  corrosive  sublimate  might  prove  poisonous,  it 


PUERPERAL    SEPTICAEMIA.  651 

would  be  well  that  such  intra-uterine  injections  should  not  be  stronger 
than  1  :  2000,  and  that  they  should  be  practised  by  the  medical  man 
himself,  the  quantity  for  such  irrigation  not  exceeding  two  quarts.1 
One  or  other  of  these  may  be  advantageously  used  alternately — one  in 
the  morning,  the  other  in  the  evening.  Occasionally  I  have  employed 
a  1  :  50  solution  of  carbolic  acid,  with  about  5  grains  to  the  ounce  of 
iodoform  suspended  in  it.  This  has  the  advantage  of  not  only  being  a 
powerful  antiseptic,  but  of  acting  more  continuously  in  consequence  of 
the  powdered  iodoform  remaining  partially  attached  to  the  uterine 
walls;  or,  as  some  have  advised,  an  iodoform  bougie2  may  be  placed 
in  the  uterine  cavity,  or  powdered  iodoform  insufflated  through  the 
cervix.  The  nozzle  of  the  syringe  should  be  guided  well  through  the 
cervix,  and  the  cavity  of  the  uterus  thoroughly  washed  out  until  the 
fluid  that  issues  from  the  vagina  is  no  longer  discolored.  As  the  os  is 
always  patulous,  there  is  no  risk  of  producing  the  troublesome  symp- 
toms of  uterine  colic,  which  occasionally  follow  the  use  of  intra-uterine 
'injections  in  the  unimpregnated  state.  It  is  quite  useless  to  intrust 
the  injection  to  the  nurse,  and  it  should  be  performed  at  least  twice 
daily  by  the  practitioner  himself,  in  all  cases  in  which  the  discharges 
are  offensive.  It  is  not  advisable,  however,  that  such  injections  should 
be  used  indiscriminately,  since  they  are  not  entirely  free  from  risk 
and  may  even  be  the  means  of  introducing  fresh  septic  matter  into  the 
uterine  cavity.  It  has  been  pointed  out3  that  sometimes  the  intra- 
uterine  injection  itself  produces  rigors  and  other  nervous  troubles.  I 
am  certain  that  this  observation  is  correct,  and  I  have  myself  more 
than  once  seen  a  severe  rigor  rapidly  follow  its  administration.  In 
any  case  it  is  useless  to  continue  the  use  of  intra-uterine  injections  for 
more  than  one  or  two  days ;  they  may  be  serviceable  in  the  earlier 
stages  of  the  disease,  but  when  systemic  infection  has  occurred  they 
cease  to  be  of  use.  The  vulva  should  in  all  cases  be  carefully  inspected 
with  the  view  of  ascertaining  if  the  source  of  infection  be  not  some 
local  slough  or  necrotic  ulcer  about  the  perineum  or  orifice  of  the 
vagina,  in  which  case  its  surface  should  be  freely  covered  with  iodo- 
form. I  have  seen  more  than  one  instance  in  which  this  simple 
procedure  has  sufficed  to  cut  short  symptoms  of  a  very  threatening 
character. 

Curetting  the  Uterine  Cavity. — Curetting4  the  interior  of  the 
uterus  has  been  strongly  recommended  and  largely  practised,  especially 
in  Vienna.  It  may  obviously  be  valuable  in  cases  in  which  retention  of 
portions  of  the  placenta  or  membranes  is  suspected,  or  in  which  a 
highly  offensive  discharge  leads  us  to  think  that  a  necrosed  condition 
of  the  decidua  may  exist.  The  patient  is  placed  in  the  semi-prone 
position,  the  vagina  irrigated  with  a  sublimate  solution  and  the  ante- 
rior lip  of  the  cervix  drawn  down  with  a  volsclla,  and  the  cudometrium 
thoroughly  scraped  with  a  blunt  curette.  The  cavity  of  the  uterus  is 

1  Herff:    "Ueber  Ursachen  und  Verhiltung  der  Sublimat-Vergiftung,"  etc.,  Arch.  f.  Gyniik., 
1885,  Bd.  xxv.  S.  487. 

*  These  may  be  made  of  gum  arable  and  glycerin,  about  two  and  a  half  inches  in  length,  each 
containing  'JO  grains  of  iodoform. 

3  Mangin :    "Quelqnes  accidents  provoques  par  lus  injections    intra-utermes,      Aouv.   Arch. 
d'Obstet.  et  de  Gyn.,  1888,  p.  3-*. 

*  See  Weiss  on  "  Curettement  in  Puerperal  Septiciemia,"  Amer.  Journ.  of  Obstet ,  August,  UNK 


652  THE    PUERPERAL    STATE. 

subsequently  well  swabbed  out  with  tincture  of  iodine.  It  can  be 
readily  understood  that  such  a  procedure  is  more  thorough  and  com- 
plete than  intra-uterine  injection,  and  there  can  be  no  objection  to  a 
careful  use  of  it  in  hands  tolerably  expert  in  obstetric  manipulations. 
It  must,  however,  be  only  practised  in  exceptional  cases,  and  with 
great  caution,  since  any  roughness  might  seriously  injure  the  uterine 
structures. 

Administration  of  Pood  and  Stimulants. — In  a  disease  char- 
acterized by  so  marked  a  tendency  to  prostration,  the  importance  of 
sustaining  the  vital  powers  by  an  abundance  of  easily  assimilated  nour- 
ishment cannot  be  overrated.  Strong  beef-tea  or  other  forms  of  animal 
soup,  milk,  alone  or  mixed  either  with  lime-  or  soda-water,  and  the 
yelk  of  eggs,  beat  up  with  milk  and  brandy,  should  be  given  at  short 
intervals  and  in  as  large  quantities  as  the  patient  can  be  induced  to 
take ;  and  the  value  of  thoroughly  efficient  nursing  will  be  especially 
apparent  in  the  management  of  this  important  part  of  the  treatment. 
As  there  is  frequently  a  tendency  to  nausea  the  patient  may  resist  the 
administration  of  food,  and  the  resources  of  the  practitioner  will  be 
taxed  in  administering  it  in  such  form  and  variety  as  will  prove  least 
distasteful.  Generally  speaking,  not  more  than  one  or  two  hours  should 
be  allowed  to  elapse  without  some  nutriment  being  given.  The  amount 
of  stimulant  required  will  vary  with  the  intensity  of  the  symptoms  and 
the  indications  of  debility.  Generally,  stimulants  are  well  borne,  prove 
decidedly  beneficial,  and  require  to  be  given  pretty  freely.  In  cases 
of  moderate  severity  a  tablespoonful  of  good  old  brandy  or  whiskey 
every  four  hours  may  suffice ;  but  when  the  pulse  is  very  rapid  and 
thready,  when  there  is  much  low  delirium,  tympanites,  or  sweating 
(indicating  profound  exhaustion),  it  may  be  advisable  to  give  them  in 
much  larger  quantities  and  at  shorter  intervals.  The  careful  practi- 
tioner will  closely  watch  the  effects  produced,  and  regulate  the  amount 
by  the  state  of  the  patient  rather  than  by  any  fixed  rule  ;  but  in  severe 
cases  eight  or  twelve  ounces  of  brandy,  or  even  more,  in  the  twenty-four 
hours  may  be  given  with  decided  benefit. 

Venesection,  both  general  and  local,  was  long  considered  a  sheet- 
anchor  in  this  disease.  Modern  views  are,  however,  entirely  opposed 
to  its  use ;  and  in  a  disease  characterized  by  so  profound  an  alteration 
of  the  blood  and  so  much  prostration,  it  is  too  dangerous  a  remedy  to 
employ,  although  it  is  possible  that  it  might  alleviate  temporarily  the 
severity  of  some  of  the  symptoms,  especially  in  cases  in  which  perito- 
nitis is  well  marked  and  much  local  pain  and  tenderness  are  present. 

Medicinal  Treatment. — The  rational  indications  in  medical  treat- 
ment are  to  lessen  the  force  of  the  circulation  as  much  as  is  possible 
without  favoring  exhaustion,  and  to  diminish  the  temperature. 

For  the  former  purpose  Barker  strongly  advocated  the  use  of  vera- 
trum  viride,  in  doses  of  five  drops  of  the  tincture  every  hour,  until  the 
pulse  falls  to  below  100,  when  its  effects  are  subsequently  kept  up  by  two 
or  three  drops  every  second  hour.  Of  this  drug  I  have  no  personal  ex- 
perience ;  but  I  have  extensively  used  minute  doses  of  tincture  of  aconite 
for  the  same  purpose,  and,  when  carefully  given,  I  believe  it  to  be  a 
most  valuable  remedy.  The  way  I  have  administered  it  is  to  give  a 


PUERPERAL    SEPTICAEMIA.  653 

single  drop  of  the  tincture,  at  first  every  half-hour,  increasing  the 
interval  of  administration  according  to  the  effect  produced.  Generally, 
after  giving  four  or  five  doses  at  intervals  of  half  an  hour,  the  pulse 
begins  to  fall,  and  afterward  a  few  doses  at  intervals  of  one  or  two 
hours  will  suffice  to  prevent  the  heart's  action  rising  to  its  former 
rapidity.  The  advantage  of  thus  modifying  the  cardiac  action,  with 
the  view  of  preventing  excessive  waste  of  tissue,  cannot  be  questioned. 
It  is  evident  that  so  powerful  a  remedy  must  not  be  used  without  the 
most  careful  supervision,  for,  if  continued  too  long,  or  given  at  too 
frequent  intervals,  it  may  unduly  depress  the  circulation  and  do  more 
harm  than  good.  It  is  necessary,  therefore,  that  the  practitioner 
should  constantly  watch  the  effect  of  the  drug,  and  stop  it  if  the  pulse 
become  very  weak,  or  if  it  intermit.  It  is  most  likely  to  be  useful  at 
an  early  stage  of  the  disease  before  much  exhaustion  is  present,  and 
then  only  when  the  pulse  is  of  a  certain  force  and  volume.  Barker 
says  of  the  veratrum  viride,  what  is  also  true  of  aconite,  that  "  it 
should  not  be  given  in  those  cases  in  which  rapid  prostration  is  man- 
ifested by  a  feeble,  thread-like,  irregular  pulse,  profuse  sweats,  and 
cold  extremities." 

The  Reduction  of  Temperature  must  form  an  important  part  of 
our  treatment,  and  for  this  purpose  many  agents  are  at  our  disposal. 

Quinine  in  large  doses,  of  from  10  to  30  grains,  has  been  much 
used  for  this  purpose,  especially  in  Germany.  After  its  exhibition 
the  temperature  frequently  falls  one  or  two  degrees.  It  may  be  given 
morning  and  evening.  Unpleasant  head-symptoms,  deafness,  and 
ringing  in  the  ears  often  render  its  continuance  for  a  length  of  time 
impossible.  These  may,  however,  be  much  lessened  by  the  addition 
of  10  to  1 5  minims  of  hydrobromic  acid  to  each  dose. 

Antipyrine  in  doses  of  20  grains  every  three  or  four  hours  some- 
times proves  very  efficacious ;  but,  as  it  is  apt  to  depress,  it  should  be 
combined  with  some  stimulant,  such  as  30  minims  of  sal-volatile.  • 

Salicylic  acid,  in  doses  of  from  10  to  20  grains,  or  the  salicylate  of 
soda  in  the  same  doses,  is  a  valuable  antipyretic  which  I  have  found 
on  the  whole  more  manageable  than  quinine.  Under  its  use  the 
temperature  often  falls  considerably  in  a  short  space  of  time.  It  is, 
however,  apt  to  depress  the  circulation,  and  thus  requires  to  be  care- 
fully watched  while  it  is  being  administered ;  and  should  the  pulse 
become  very  small  and  feeble,  it  should  be  discontinued. 

In  some  cases,  especially  when  the  fever  has  assumed  a  remittent 
type,  I  have  administered  with  marked  benefit  a  drug  which  is  of 
high  repute  in  India  in  the  worst  class  of  malarious  remittent  fevers, 
and  the  almost  marvellous  effects  of  which  in  such  cases  I  had  myself 
witnessed  in  India  many  years  ago.  This  is  the  so-called  Warburg's 
tincture,  the  value  of  which  has  been  testified  to  by  many  high  authori- 
ties, among  whom  I  may  mention  Dr.  Maclean,  of  Netley,  Dr.  Broad- 
bent,  and  Sir  Alexander  Armstrong,  the  Director-General  of  the 
Medical  Department  of  the  Navy,  who  informs  me  that  it  is  now  sup- 
plied to  all  Her  Majesty's  ships  in  the  tropics,  because  it  is  found  to 
be  of  the  utmost  value  in  cases  in  which  quinine  has  little  or  no  effect. 
Recently  its  composition  has  been  made  public  by  Dr.  Maclean.  The 


654  THE    PUERPERAL    STATE. 

basis  is  quinine,  in  combination  with  various  aromatics  and  bitters, 
some  of  which  probably  intensify  its  action.  Be  this  as  it  may,  the  testi- 
mony in  favor  of  the  antipyretic  action  of  the  remedy  is  very  strong. 
I  have  found  its  exhibition  followed  by  a  profuse  diaphoresis  (this 
being  its  almost  invariable  effect),  and  sometimes  a  rapid  amelioration 
of  the  symptoms.  In  other  cases  in  which  I  have  tried  it,  like  every- 
thing else,  it  has  proved  of  no  avail.  Of  its  use  in  ten  malarial  cases 
above  alluded  to,  Dr.  Fordyce  Barker  says :  "  For  nearly  two  years 
past,  in  those  cases  where  the  stomach  will  tolerate  it,  I  have  found 
Warburg's  tincture  much  more  effective  and  speedy  in  producing  the 
results  desired  than  the  largest  doses  of  quinine."  l 

Application  of  Cold. — Cold  may  be  advantageously  tried  in  suit- 
able cases.  The  simplest  mode  of  using  it  is  by  Thornton's  ice-cap, 
by  which  a  current  of  cold  water  is  kept  continuously  running  round 
the  head.  This  has  been  found  of  great  value  in  pyrexia  after  ovari- 
otomy, and  I  have  also  found  it  useful  as  a  means  of  reducing  tempera- 
ture in  puerperal  cases.  It  is  a  comforting  application  and  gives  great 
relief  to  the  throbbing  headache,  which  often  causes  much  suffering. 
Under  its  use  the  temperature  often  falls  two  or  more  degrees,  and  it 
is  easily  continued  day  and  night. 

In  very  serious  cases,  when  the  temperature  reaches  105°  or  upward, 
the  external  application  of  cold  to  the  rest  of  the  body  may  be  tried. 
I  have  elsewhere  related2  a  case  of  puerperal  septicaemia  with  hyper- 
pyrexia,  the  temperature  continuously  ranging  over  105°,  in  which  I 
kept  the  patient  for  eleven  days  nearly  constantly  covered  with  cloths 
soaked  in  iced  water,  by  which  means  only  was  the  temperature  kept 
within  moderate  bounds  and  life  preserved.  But  this  method  of  treat- 
ment is  excessively  troublesome,  and  is  in  no  way  curative.  It  is 
only  of  use  in  moderating  the  temperature  when  it  has  reached  a  point 
at  which  it  could  not  continue  long  without  destroying  the  patient. 
I  should,  therefore,  never  think  of  employing  it  unless  the  temperature 
was  over  105°,  and  then  only  as  a  temporary  expedient,  requiring 
incessant  watching,  to  be  desisted  from  as  soon  as  the  temperature  had 
reached  a  more  moderate  height.  It  is  clearly  impossible  to  place  a 
puerperal  patient  in  a  bath,  as  is  practised  in  hyperpyrexia  associated 
with  acute  rheumatism  or  typhoid  fever.  The  same  effect  may,  how- 
ever, be  obtained  by  placing  her  on  mackintosh  sheeting,  or  still  better 
on,  a  water-bed,  into  which  cold  water  is  run  from  time  to  time,  and 
covering  the  body  with  towels  soaked  in  ice-water,  which  are  fre- 
quently renewed  by  the  attendant  nurses.  During  the  application  the 
temperature  should  be  constantly  taken,  and  as  soon  as  it  has  fallen 
to  101°  the  cold  application  should  be  discontinued. 

Administration  of  Turpentine. — Amongst  other  remedies  which 
have  been  used  is  turpentine,  which  was  highly  thought  of  by  the 
Dublin  school.  In  cases  with  much  tympanitic  distention,  and  a  small 
weak  pulse,  it  is  sometimes  of  unquestionable  value,  and  it  probably 
acts  as  a  strong  nervine  stimulant.  Given  in  doses  of  1 5  to  20  minims 

1  Op.  cit.,  p.  278. 

*  "  A  Lecture  on  a  Case  of  Puerperal  Septicaemia  with  Hyperpyrexia,  treated  by  the  Continuous 
Application  of  Cold,"  Brit.  Med.  Journ.,  1877,  vol.  ii.  p.  687. 


655 

rubbed  up  with  mucilage,  it  can  generally  be  taken  in  spite  of  its 
nauseous  taste. 

Bvacuant  Remedies. — Purgatives,  diaphoretics,  or  even  emetics, 
have  often  been  employed  as  eliminants  of  the  poison.  The  former 
are  strongly  recommended  by  Schroeder  and  other  German  authorities, 
and  in  England  they  were  formerly  amongst  the  most  favorite 
remedies,  and  there  is  a  general  concurrence  of  opinion  amongst  our 
older  writers  as  to  their  value.  In  the  first  volume  of  the  Obstetrical 
Journal  there  is  a  paper  by  Mr.  Morton,  in  which  this  practice  is 
strongly  advocated,  and  some  interesting  cases  are  recorded  in  which 
it  apparently  acted  well.  He  administers  calomel  in  doses  of  3  or  4 
grains  with  compound  extract  of  colocynth,  so  as  to  keep  up  a  free 
action  of  the  bowels.  It  seems  quite  reasonable,  when  there  is  con- 
stipation, to  promote  a  gentle  action  of  the  bowels  by  some  mild 
aperient ;  but,  bearing  in  mind  that  severe  and  exhausting  diarrhoea  is 
a  common  accompaniment  of  the  disease,  I  should  myself  hesitate  to 
run  the  risk  of  inducing  it  artificially,  especially  as  there  is  no  proof 
whatever  that  septic  matter  can  really  be  eliminated  in  this  way.  At 
the  commencement  of  the  disease,  however,  I  have  often  given  one  or 
two  aperient  doses  of  calomel  with  decided  benefit. 

Internal  Antiseptic  Remedies. — It  is  possible  that  further  research 
will  give  us  some  means  of  counteracting  the  septic  state  of  the  blood ; 
and  the  sulphites  and  carbolates  have  been  given  for  this  purpose,  but 
as  yet  with  no  reliable  results. 

The  tincture  of  the  perchloride  of  iron  naturally  suggests  itself, 
from  its  well-known  effects  in  surgical  pyaemia.  In  the  less  intense 
forms  of  the  disease,  especially  when  local  suppurations  exist,  it  is 
certainly  useful,  and  may  be  given  in  doses  of  10  to  20  minims  every 
three  or  four  hours.  In  very  acute  cases  other  remedies  are  more 
reliable,  and  the  iron  has  the  disadvantage  of  not  unfrequently  causing 
nausea  or  vomiting. 

When  restlessness,  irritation,  and  want  of  sleep  are  prominent 
symptoms,  sedatives  may  be  required.  Under  such  circumstances 
opiates  may  be  given  at  night,  and  Battley's  solution,  nepenthe,  or-  the 
hypodermic  injection  of  morphia  is  the  form  which  answers  best. 

Treatment  of  Local  Complications. — Pain,  tenderness,  and  local 
complications  must  be  treated  on  general  principles.  The  distress 
from  them  is  most  experienced  when  peritonitis  is  well  marked.  Then, 
warm  and  moist  applications,  in  the  form  of  poultices  or  fomentations, 
are  very  useful.  Relief  is  also  sometimes  obtained  from  turpentine 
stupes,  and  when  the  tympanites  is  distressing,  turpentine  enemata  are 
very  serviceable.  I  have  found  the  free  application  over  the  abdomen 
of  the  flexible  collodium  of  the  Pharmacopeia  decidedly  useful  in  alle- 
viating the  suffering  from  peritonitis. 

Coeliotomy  in  cases  of  puerperal  peritonitis  has  been  discussed  and 
practised  within  the  last  few  years.1  The  subject  is  too  new,  and,  as 
yet,  experience  far  too  small,  to  justify  any  dogmatic  opinion  as  to  its 

1  See  Maury,  "  The  Indications  for  Cceliotomy  in  Puerperal  Fever,"  and  Hirst,  "  The  Position  of 
Abdominal  Section  in  the  Treatment  of  Septic  Peritonitis  after  Childbirth,"  Trans,  of  the  Amer. 
Gyn.  Soc.,  1891. 


656  THE    PUERPERAL    STATE. 

merits  or  demerits.  So  far  as  existing  evidence  seems  to  show,  the 
successful  cases  have  been  examples  of  localized  pus  deposits,  more  in 
the  nature  of  pelvic  peritonitis,  or,  in  a  few  cases,  of  general  sup- 
purative  peritonitis.  In  the  latter  class  the  operation  has  been  per- 
formed a  considerable  time  after  delivery,  such  as  six  weeks,  but  cases 
of  this  kind  cannot  with  propriety  be  called  true  puerperal  septicaemia. 
The  few  cases  reported  in  which  coeliotomy  has  been  performed  soon 
after  the  development  of  septic  symptoms  appear  all  to  have  ended 
fatally.  This  is  exactly  what  one  would  have  a  priori  expected.  In 
acute  septic  infection,  which  is  a  general  and  not  a  local  disease,  there 
are,  it  is  true,  very  often  marked  symptoms  of  peritoneal  disease,  such 
as  tenderness,  immense  distention,  and  the  like ;  but  this  is  one  only  of 
many  local  phenomena.  To  open  the  abdomen  in  such  cases  would  be 
rash  in  the  extreme,  and  a  most  hopeless  procedure  ;  it  might  even  be 
impossible  to  return  the  enormously  inflated  intestines.  It  has  been 
said  that  coeliotomy  to  be  of  use  in  cases  of  this  kind  must  be  done 
early,  but  it  is  to  be  remembered  that  in  the  early  stages  of  septicaemia 
the  symptoms  are  not  well  marked.  The  hope  of  cutting  them  short 
has  not  been  abandoned,  and  it  would  lead  to  deplorable  results  if 
advice  of  this  kind  should  lead  to  opening  the  abdomen  of  puerperal 
patients  as  soon  as  suspicious  symptoms  arose.  In  the  former  class, 
however,  it  is  certain  that  in  well-selected  cases  coeliotomy,  washing 
out  of  the  abscess  cavity  or  peritoneum,  and  drainage,  offer  by  far  the 
best  prospects  of  recovery. 

Such  are  the  remedies  most  used  in  this  disease.  It  is  needless  to 
say  that  it  is  quite  impossible  to  lay  down  fixed  rules  for  the  manage- 
ment of  any  individual  case ;  and  it  is  obvious  that,  if  puerperal  septi- 
caemia be  not  a  special  and  distinct  disease,  its  judicious  treatment  must 
depend  on  the  general  knowledge  of  the  attendant  and  on  a  careful 
study  of  the  symptoms  each  separate  case  presents. 


CHAPTER   VI. 

PUERPERAL   VENOUS  THROMBOSIS  AND   EMBOLISM. 

Puerperal  Thrombosis  and  its  Results. — Under  the  head  of 
thrombosis  we  may  class  several  important  diseases  connected  with  the 
puerperal  state,  which  have  received  far  less  attention  than  they  deserve. 
It  is  only  of  late  years  that  some,  we  may  probably  safely  say  the 
majority,  of  those  terribly  sudden  deaths  which  from  time  to  time  occur 
after  delivery  have  been  traced  to  their  true  cause,  viz.,  obstruction  of 
the  right  side  of  the  heart  and  pulmonary  arteries  from  a  blood-clot, 
either  carried  from  a  distance  or,  as  I  shall  hope  to  show,  formed  in 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.      657 

situ.  Although  the  result  and,  to  a  great  extent,  the  symptoms,  are 
identical  in  both,  still  a  careful  consideration  of  the  history  of  these 
two  classes  of  cases  tends  to  show  that  in  their  production  they  are 
distinct,  and  that  they  ought  not  to  be  confounded.  In  the  former  we 
have  primarily  a  clotting  of  blood  in  some  part  of  the  peripheral 
venous  system,  and  the  separation  of  a  portion  of  such  a  thrombus 
due  to  changes  undergone  during  retrograde  metamorphosis  tending  to 
its  eventual  absorption.  In  the  latter  we  have  a  local  depositing  of 
fibrin,  the  result  of  blood  changes  consequent  on  pregnancy  and  the 
puerperal  state.  The  formation  of  such  a  coagulum  in  vessels  the 
complete  obstruction  of  which  is  incompatible  with  life,  explains  the 
fatal  results.  When,  however,  a  coagulum  chances  to  be  formed  in 
more  distant  parts  of  the  circulation,  the  vital  functions  are  not  imme- 
diately interfered  with,  and  we  have  other  phenomena  occurring,  due 
to  the  obstruction.  The  disease  known  as  phlegmasia  dolens,  I  shall 
presently  attempt  to  show,  is  one  result  of  blood-clot  forming  in  periph- 
eral vessels.  But  from  the  evident  and  tangible  symptoms  it  pro- 
duces, it  has  long  been  considered  an  essential  and  special  disease,  and 
the  general  blood  dyscrasia  which  produces  it,  as  well  as  other  allied 
states,  has  not  been  studied  separately.  I  shall  hope  to  show  that  all 
these  various  conditions,  dissimilar  as  they  at  first  sight  appear,  are 
very  closely  connected,  and  that  they  are  in  fact  due  to  a  common 
cause ;  and  thus,  I  think,  we  shall  arrive  at  a  clearer  and  more  correct 
idea  of  their  true  nature  than  if  we  looked  upon  them  as  distinct  and 
separate  affections,  as  has  been  commonly  done.  I  am  aware  that  in 
phlegmasia  dolens,  the  pathology  of  which  has  received  perhaps  more 
study  than  that  of  almost  any  other  puerperal  affection,  something 
beyond  simple  obstruction  of  the  venous  system  of  the  affected  limb  is 
probably  required  to  account  for  the  peculiar  tense  and  shining  swelling 
which  is  so  characteristic.  Whether  this  be  an  obstruction  of  the 
lymphatics,  as  Dr.  Tilbury  Fox  and  others  have  maintained  with  much 
show  of  reason,  or  whether  it  is  some  as  yet  undiscovered  state,  further 
investigation  is  required  to  show.  But  it  is  beyond  any  doubt  that  the 
important  and  essential  part  of  the  disease  is  the  presence  of  a  thrombus 
in  the  vessels;  and  I  think  it  will  not  be  difficult  to  prove  that  in  its 
causation  and  history  it  is  precisely  similar  to  the  more  serious  cases  in 
which  the  pulmonary  arteries  are  involved. 

It  will  be  well  to  commence  the  study  of  the  subject  by  a  considera- 
tion of  the  conditions  which,  in  the  puerperal  state,  render  the  blood 
so  peculiarly  liable  to  coagulation,  and  we  may  then  proceed  to  discuss 
the  symptoms  and  results  of  the  formation  of  coagula  in  various  parts 
of  the  circulatory  system. 

Conditions  which  Favor  Thrombosis. — The  researches  of  Vir- 
chow,  Benjamin  Ball,  Humphry,  Richardson,  and  others  have  rendered 
us  tolerably  familiar  with  the  conditions  which  favor  the  coagulation 
of  the  blood  in  the  vessels.  These  are  chiefly:  1.  A  stagnant  or 
arrested  circulation  ;  as,  for  example,  when  the  blood  coagulates  in  the 
veins  which  draw  blood  from  the  gluteal  region  in  old  and  bedridden 
people,  or,  as  in  some  forms  of  pulmonary  thrombosis,  in  which  the 
clots  in  the  arteries  are  probably  the  result  of  obstruction  in  the  circu- 

42 


658  THE    PUERPERAL    STATE. 

lation  through  the  lung-capillaries,  as  in  certain  cases  of  emphysema, 
pneumonia,  or  pulmonary  apoplexy.  2.  A  mechanical  obstruction 
around  which  coagula  form,  as  in  certain  morbid  states  of  the  vessels . 
or,  a  better  example  still,  secondary  coagula  which  form  around  a 
travelled  ernbolus  impacted  in  the  pulmonary  arteries.  3.  And  most 
important  of  all,  in  which  the  coagulation  is  the  result  of  some  morbid 
state  of  the  blood  itself.  Examples  of  this  last  condition  are  fre- 
quently met  with  in  the  course  of  various  diseases,  such  as  rheumatism 
or  fever,  in  which  the  quantity  of  fibrin  is  increased  and  the  blood 
itself  is  loaded  with  morbid  material.  Thrombosis  from  this  cause  is 
of  by  no  means  infrequent  occurrence  after  severe  surgical  operations, 
especially  such  as  have  been  attended  with  much  hemorrhage,  or  when 
the  patient  is  in  a  weak  and  anaemic  condition.  This  has  been  specially 
dwelt  upon,  as  a  not  uufrequent  source  of  death  after  operation,  by 
Fayrer  and  other  surgeons.1 

Coagulation  in  the  Puerperal  State. — But  little  consideration  is 
required  to  show  why  thrombosis  plays  so  important  a  part  in  the 
puerperal  state,  for  there  most  of  the  causes  favoring  its  occurrence 
are  present.  Probably  there  is  no  other  condition  in  which  they  exist 
in  so  marked  a  degree,  or  are  so  frequently  combined.  The  blood 
contains  an  excess  of  fibrin,  which  largely  increases  in  the  latter 
months  of  utero-gestation,  until,  as  has  been  pointed  out  by  Andral 
and  Gavarret,  it  not  uufrequently  contains  a  third  more  than  the 
average  amount  present  in  the  non-pregnant  state.  As  soon  as  delivery 
is  completed,  other  causes  of  blood-dyscrasia  come  into  operation. 
Involution  of  the  largely  hypertrophied  uterus  commences,  and  the 
blood  is  charged  with  a  quantity  of  effete  material,  which  must  be 
present  in  greater  or  less  amount  until  that  process  is  completed.  It 
is  an  old  observation  that  phlegmasia  dolens  is  of  very  common  occur- 
rence in  patients  who  have  lost  much  blood  during  labor.  Thus  Dr. 
Leishman  says:  "In  no  class  of  cases  has  it  been  so  frequently 
observed  as  in  women  wrhose  strength  has  been  reduced  to  a  low  ebb 
by  hemorrhage  either  during  or  after  labor,  and  this,  no  doubt, 
accounts  for  the  observation  made  by  Merriman,  that  it  is  relatively  a 
common  occurrence  after  placenta  prsevia."2  An  examination  of  the 
cases  in  which  death  results  from  pulmonary  thrombosis  shows  the 
same  facts,  as  in  a  large  proportion  of  them  severe  post-partum  hem- 
orrhag  has  occurred.  The  exhaustion  following  the  excessive  losses 
so  common  after  labor  must  of  itself  strongly  predispose  to  throm- 
bosis and,  indeed,  loss  of  blood  has  been  distinctly  pointed  out  by 
Richardson  to  be  one  of  its  most  common  antecedents.  "  There  is," 
he  observes,  "  a  condition  which  has  been  long  known  to  favor  coagu- 
lation and  fibriuous  deposition.  I  mean  loss  of  blood  and  syncope  or 
exhaustion  during  impoverished  states  of  the  body." 

Since,  then,  so  many  of  the  predisposing  causes  of  thrombosis  are 
present  in  the  puerperal  state,  it  is  hardly  a  matter  of  astonishment 
that  it  should  be  of  frequent  occurrence  or  that  it  should  lead  to  con- 
ditions of  serious  gravity.  And  yet  the  attention  of  the  profession 

i  Edin.  Med.  Journ.,  March,  1861 ;  Indian  Annals  of  Med.,  July,  1887. 
1  Leishman  :  System  of  Obstetrics,  p.  720.    2nd  edition,  1876. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.      659 

has  been  for  the  most  part  limited  to  a  study  of  only  one  of  the  results 
of  this  tendency  to  blood-clotting  after  delivery,  no  doubt  because  of  its 
comparative  frequency  and  evident  symptoms.  True,  the  balance  of 
professional  opinion  has  lately  held  that  phlegmasia  dolens  is  chiefly 
the  result  of  some  morbid  condition  of  the  blood,  producing  plugging 
of  the  veins ;  but  the  wider  view  which  I  am  attempting  to  maintain, 
which  would  bring  this  disease  into  close  relation  with  the  more  rarely 
observed,  but  infinitely  important,  obstructions  of  the  pulmonary 
arteries,  has  scarcely,  if  at  all,  been  insisted  on.  Doubtless  further 
investigation  will  show  that  it  is  not  in  these  parts  of  the  venous 
system  alone  that  puerperal  thrombosis  occurs ;  but  the  symptoms  and 
effects  of  venous  obstruction  elsewhere,  important  though  they  may 
be,  are  unknown. 

Distinction  between  Thrombosis  and  Embolism. — I  propose, 
then,  to  describe  the  symptoms  and  pathology  of  blood-clot  in  the 
right  side  of  the  heart  and  pulmonary  artery.  It  may  be  useful  here 
to  repeat  that  this  is  essentially  distinct  from  embolism  of  the  same 
parts.  The  latter  is  obstruction  due  to  the  impaction  of  a  separated 
portion  of  a  thrombus  formed  elsewhere,  and  for  its  production  it  is 
essential  that  thrombosis  should  have  preceded  it.  Embolism  is,  in 
fact,  an  accident  of  thrombosis,  not  a  primary  affection.  The  condi- 
tion we  are  now  discussing  I  hold  to  be  primary,  precisely  similar  in 
its  causation  to  the  venous  obstruction  which,  in  other  situations,  gives 
rise  to  phlegmasia  dolens. 

At  the  threshold  of  this  inquiry  we  have  to  meet  the  objection 
started  by  several  who  have  written  on  this  subject,1  that  spontaneous 
coagulation  of  the  blood  in  the  right  side  of  the  heart  and  pulmonary 
arteries  is  a  mechanical  and  physiological  impossibility.  This  was 
the  view  of  Virchow,  who,  with  his  followers,  maintained  that  when- 
ever death  from  pulmonary  obstruction  occurred,  an  embolus  was  of 
necessity  the  starting-point  of  the  malady  and  the  nucleus  round 
which  secondary  deposition  of  fibrin  took  place.  Virchow  holds  that 
the  primary  factor  in  thrombosis  is  a  stagnant  state  of  the  blood,  and 
that  the  impulse  imparted  to  the  blood  by  the  right  ventricle  is  of 
itself  sufficient  to  prevent  coagulation.  It  is  to  be  observed  that  these 
objections  are  purely  theoretical.  Without  denying  that  there  is  con- 
siderable force  in  the  arguments  adduced,  I  think  that  the  clinical 
history  of  these  cases  strongly  favors  the  view  of  spontaneous  coagu- 
lation ;  and  I  would  apply  to  the  theoretical  objections  advanced  the 
argument  used  by  one  of  their  strongest  upholders  with  regard  to 
another  disputed  point :  "  Je  pref  ere  laisser  la  parole  aux  faits,  car 
devant  enx  la  theorie  s'incline." 2 

The  anatomical  arrangement  of  the  pulmonary  arteries  shows  how 
spontaneous  coagulation  may  be  favored  in  them ;  for,  as  Humphry 
has  pointed  out,3  "the  artery  breaks  up  at  once  into  a  number  of 
branches,  which  radiate  from  it,  at  different  angles  to  the  several  parts 
of  the  lungs.  Consequently  a  large  extent  of  surface  is  presented  to 

'  See  especially  Berlin :  Des  Embolies,  p.  46  et  seq. 

*  Berlin;  Des  Embolies,  p.  149. 

»  Humphry  :  On  the  Coagulation  of  the  Blood  in  the  Venous  System  during  Life. 


660  THE    PUERPERAL    STATE. 

the  blood,  and  there  are  numerous  angular  projections  into  the  cur- 
rents, both  which  conditions  are  calculated  to  induce  the  spontaneous 
coagulation  of  the  fibrin."  We  know  also  that  thrombosis  generally 
occurs  in  patients  of  feeble  constitution,  often  debilitated  by  hemor- 
rhage, in  whom  the  action  of  the  heart  is  much  weakened.  These 
facts  of  themselves  go  far  to  meet  the  objections  of  those  who  deny 
the  possibility  of  spontaneous  coagulation  at  the  roots  of  the  pulmo- 
nary arteries. 

Results  of  Post-mortem  Examinations. — The  records  of  post- 
mortem examinations  show  also  that  in  many  of  the  cases  the  right 
side  of  the  heart,  as  well  as  the  larger  branches  of  the  pulmonary 
arteries,  contained  firm,  leathery,  decolorized,  and  laminated  coagula, 
which  could  not  have  been  recently  formed.  The  advocates  of  the 
purely  embolic  theory  maintain  that  these  are  secondary  coagula, 
formed  round  an  embolus.  But  surely  the  mechanical  causes  which 
are  sufficient  to  prevent  spontaneous  deposition  of  fibrin  would  also 
suffice  to  prevent  its  gathering  round  an  embolus;  unless,  indeed,  the 
obstruction  was  sufficient  to  arrest  the  circulation  altogether,  when 
death  would  occur  before  there  was  any  time  for  a  secondary  deposit. 
Before  we  can  admit  the  possibility  of  embolism  we  must  have  at  least 
one  factor — that  is,  thrombosis — in  a  peripheral  vessel,  from  which  an 
embolus  can  come.  In  many  of  the  recorded  cases  nothing  of  the 
kind  was  found,  and  although,  as  is  argued,  this  may  have  been  over- 
looked, yet  such  an  oversight  can  hardly  always  have  been  made. 

The  strongest  argument,  however,  in  favor  of  the  spontaneous  origin 
of  pulmonary  thrombosis  is  one  which  I  originally  pointed  out  in  a 
series  of  papers  "On  Thrombosis  and  Embolism  of  the  Pulmonary 
Artery  as  a  Cause  of  Death  in  the  Puerperal  State."1  I  there  showed 
from  a  careful  analysis  of  25  cases  of  sudden  death  after  delivery,  in 
which  accurate  post-mortem  examinations  had  been  made,  that  cases 
of  spontaneous  thrombosis  and  embolism  may  be  divided  from  each 
other  by  a  clear  line  of  demarcation,  depending  on  the  period  after 
delivery  at  which  the  fatal  result  occurs.  In  7  out  of  these  cases  there 
was  distinct  evidence  of  embolism,  and  in  them  death  occurred  at  a 
remote  period  after  delivery ;  in  none  before  the  nineteenth  day.  This 
contrasts  remarkably  with  the  cases  in  which  the  post-mortem  exami- 
nation afforded  no  evidence  of  embolism.  These  amounted  to  15  out 
of  the  25,  and  in  all  of  them,  with  one  exception,  death  occurred 
before  the  fourteenth  day,  often  on  the  second  or  third.  The  reason 
of  this  seems  to  be  that,  in  the  former,  time  is  required  to  admit  of 
degenerative  changes  taking  place  in  the  deposited  fibrin  leading  to 
separation  of  an  embolus;  while  in  the  latter  the  thrombosis  corre- 
sponds in  time,  and  to  a  great  extent  no  doubt  also  in  cause,  to  the 
original  peripheral  thrombosis  from  which,  in  the  former,  the  embolus 
was  derived.  Many  cases  I  have  since  collected  illustrate  the  same 
rule  in  a  very  curious  and  instructive  way. 

Another  clinical  fact  I  have  observed  points  to  the  same  conclusion. 
In  one  or  two  cases  distinct  signs  of  pulmonary  obstruction  have 

1  Lancet,  1867. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.      661 

shown  themselves  without  proving  immediately  fatal,  and  shortly 
afterward  peripheral  thrombosis,  as  evidenced  by  phlegmasia  dolens 
of  one  extremity,  has  commenced.  Here  the  peripheral  thrombosis 
obviously  followed  the  central,  both  being  produced  by  identical 
causes,  and  the  order  of  events  necessary  to  uphold  the  purely  embolic 
theory  was  reversed. 

I  hold,  then,  that  those  who  deny  the  possibility  of  spontaneous 
coagulation  in  the  heart  and  pulmonary  arteries  do  so  on  insufficient 
grounds,  and  that  we  may  consider  it  to  be  an  occurrence,  rare  no 
doubt,  but  still  sufficiently  often  met  with,  and  certainly  of  sufficient 
importance,  to  merit  very  careful  study. 

History. — Dr.  Charles  D.  Meigs,  of  Philadelphia,  was  one  of  the 
first  to  direct  attention  to  spontaneous  coagulation  of  the  blood  in  the 
right  side  of  the  heart  and  pulmonary  arteries  as  a  cause  of  sudden 
death  in  the  puerperal  state.  The  occurrence  itself,  however,  has  been 
carefully  studied  by  Paget,  whose  paper  was  published  in  1855,  four 
years  before  Meigs  wrote  on  the  subject.1  It  is  true  that  none  of 
Paget's  cases  happened  after  delivery,  but  he  none  the  less  clearly 
apprehended  the  nature  of  the  obstruction.  In  1855,  Hecker2  attrib- 
uted the  majority  of  these  cases  to  embolism  proper ;  and  since  that 
date  most  authors  have  taken  the  same  view,  believing  that  sponta- 
neous coagulation  only  occurs  in  exceptional  cases,  such  as  those  in 
which,  on  account  of  some  obstruction  in  the  lung  or  in  the  debility 
of  the  last  few  hours  before  death,  coagula  form  in  the  smaller  rami- 
fications of  the  pulmonary  arteries,  and  gradually  creep  back  toAvard 
the  heart. 

Symptoms  of  Pulmonary  Obstruction. — The  symptoms  can 
hardly  be  mistaken,  and  there  seems  to  be  no  essential  difference 
between  the  symptomatology  of  spontaneous  and  embolic  obstructions, 
so  that  the  same  description  will  suffice  for  both.  In  a  large  propor- 
tion of  cases  the  attack  comes  on  with  an  appalling  suddenness,  which 
forms  one  of  its  most  striking  characteristics.  Nothing  in  the  con- 
dition of  the  patient  need  have  given  rise  to  the  least  suspicion  of 
impending  mischief,  when  all  at  once  an  intense  and  horrible  dyspnoea 
comes  on  ;  she  gasps  and  struggles  for  breath  ;  tears  off  the  coverings 
from  her  chest  in  a  vain  endeavor  to  get  more  air ;  and  often  dies  in 
a  few  minutes,  long  before  medical  aid  can  be  had,  with  all  the  symp- 
toms of  asphyxia.  The  muscles  of  the  face  and  thorax  are  violently 
agitated  in  the  attempt  to  oxygenate  the  blood,  and  an  appearance 
closely  resembling  an  epileptic  convulsion  may  be  presented.  The 
face  may  be  either  pale  or  deeply  cyanosed.  Thus,  in  one  case  I  have 
elsewhere  recorded,  which  was  an  undoubted  example  of  true  embolism, 
Mr.  Pedler,  the  resident  accoucheur  at  King's  College  Hospital,  who 
was  present  during  the  attack,  writes  of  the  patient  :3  "  She  was  suffer- 
ing from  extreme  dyspnoea,  the  countenance  was  excessively  pale,  her 
lips  white,  the  face  generally  expressing  deep  anxiety."  In  another, 

1  Medico-Chirur.  Trans.,  vol.  xxvii.  p.  162.  and  vol.  xxviii.  p.  352.    Philadelphia  Medical  Ex- 
aminer, 1849. 

2  Deutsche  Klinik,  1855. 

3  Brit.  Med.  Journ.,  1869,  vol.  i.  p.  282. 


662  THE    PUERPERAL    STATE. 

which  was  probably  an  example  of  spontaneous  thrombosis,1  occurring 
on  the  twelfth  day  after  delivery,  it  is  stated  :  "  The  face  had  assumed 
a  livid  purple  hue,  which  was  so  remarkable  as  to  attract  the  attention 
both  of  the  nurse  and  of  her  mother,  who  was  with  her."  The  extreme 
embarrassment  of  the  circulation  is  shown  by  the  tumultuous  and 
irregular  action  of  the  heart  in  its  endeavor  to  send  the  venous  blood 
through  the  obstructed  pulmonary  arteries.  Soon  it  gets  exhausted, 
as  shown  by  its  feeble  and  fluttering  beat.  The  pulse  is  thread-like 
and  nearly  imperceptible,  the  respirations  short  and  hurried,  but  air 
may  be  heard  entering  the  lungs  freely.  The  intelligence  during  the 
struggle  is  unimpaired ;  and  the  dreadful  consciousness  of  impending 
death  adds  not  a  little  to  the  patient's  sufferings  and  to  the  terror  of 
the  scene.  Such  is  an  imperfect  account  of  the  symptoms,  gathered 
from  a  record  of  what  has  been  observed  in  fatal  cases.  It  will  be 
readily  understood  why,  in  the  presence  of  so  sudden  and  awful  an 
attack,  symptoms  have  not  been  recorded  with  the  accuracy  of  ordinary 
clinical  observation. 

Is  Recovery  Possible  ? — A  question  of  great  practical  interest, 
which  has  been  entirely  overlooked  by  writers  on  the  subject,  is,  Have 
we  any  ground  for  supposing  that  there  is  a  possibility  of  recovery 
after  symptoms  of  pulmonary  obstruction  have  developed  themselves  ? 
That  such  a  result  must  be  of  extreme  rarity  is  beyond  question  ;  but 
I  have  little  doubt  that  in  some  few  cases,  entirely  inexplicable  on  any 
other  hypothesis,  life  is  prolonged  until  the  coagulum  is  absorbed  and 
the  pulmonary  circulation  restored.  In  order  to  admit  of  this  it  is, 
of  course,  essential  that  the  obstruction  be  not  sufficient  to  prevent  the 
passage  of  a  certain  quantity  of  blood  to  the  lungs  to  carry  on  the 
vital  functions.  The  history  of  many  cases  tends  to  show  that  the 
obstructing  clot  was  present  for  a  considerable  time  before  death,  and 
that  it  was  only  when  some  sudden  exertion  was  made,  such  as  rising 
from  bed  or  the  like,  calling  for  an  increased  supply  of  blood  which 
could  not  pass  through  the  occluded  arteries,  that  the  fatal  symptoms 
manifested  themselves.  This  was  long  ago  pointed  out  by  Paget,2  who 
says :  "  The  case  proves  that,  in  certain  circumstances,  a  great  part  of 
the  pulmonary  circulation  may  be  arrested  in  the  course  of  a  week  (or 
a  few  days,  more  or  less)  without  immediate  danger  to  life,  or  any 
indication  of  what  had  happened."  And  after  referring  to  some 
illustrative  cases :  "  Yet  in  all  these  cases  the  characters  of  the  clots 
by  which  the  pulmonary  arteries  were  obstructed  showed  plainly  that 
they  had  been  a  week  or  more  in  the  process  of  formation."  If  we 
admit  the  possibility  of  the  continuance  of  life  for  a  certain  time,  we 
must,  I  think,  also  admit  the  possibility,  in  a  few  rare  cases,  of  eventual 
complete  recovery.  AVhat  is  required  is  time  for  the  absorption  of 
the  clot.  In  the  peripheral  venous  system  coagula  are  constant!  y 
removed  by  absorption.  So  strong,  indeed,  is  the  tendency  to  thi.s, 
that  Humphry  observes  with  regard  to  it :  "  It  appears  that  the  blood 
is  almost  sure  to  revert  to  its  natural  channel  in  process  of  time."3 


1  Obst.  Trans.,  1871,  vol.  xii.  p.  194. 
0  "~    -it.,  p.  358. 

Chir.  Trans.,  vol.  xxvii.  p.  14. 


2  Op.  cit.,  p.- 358. 
«  Med.-~  '    ~ 


PUERPERAL  VENOUS  THROMBOSIS  AND  EMBOLISM.   663 

If,  then,  the  obstruction  be  only  partial,  if  sufficient  blood  pass  to  keep 
the  patient  alive,  and  a  sudden  supply  of  oxygenated  blood  is  not 
demanded  by  any  exertion  which  the  embarrassed  circulation  is  unable 
to  meet,  it  is  not  inconceivable  that  the  patient  may  live  until  the 
obstruction  is  removed. 

Illustrative  Cases. — Such  I  believe  to  be  the  only  explanation  of 
certain  cases,  some  of  which,  on  any  other  hypothesis,  it  is  impossible 
to  understand.  The  symptoms  are  precisely  those  of  pulmonary 
obstruction,  and  the  description  I  have  given  above  may  be  applied 
to  them  in  every  particular ;  and  after  repeated  paroxysms,  each  of 
which  seems  to  threaten  immediate  dissolution,  an  eventual  recovery 
takes  place.  What,  then,  I  am  entitled  to  ask,  can  the  condition  be, 
if  not  that  which  I  suggest  ?  As  the  question  I  am  considering  has 
never,  so  far  as  I  am  aware,  been  treated  of  by  any  other  writer,  I 
may  be  permitted  to  state  very  briefly  the  facts  of  one  or  two  of  the 
cases  on  which  I  found  my  argument,  some  of  which  I  have  already 
published  in  detail  elsewhere.  * 

K.  H.,  delicate  young  lady.  Labor  easy  First  child.  Profuse  post-partum  hemorrhage.  Did 
well  until  the  seventh  day,  during  the  whole  of  which  she  felt  weak.  Same  day  an  alarming  attack 
of  dyspucea  came  on.  For  several  days  she  remained  in  a  very  critical  condition,  the  slightest 
exertion  bringing  on  the  attacks.  A  slight  blowing  murmur  heard  for  a  few  days  at  the  base  of 
the  heart,  then  it  disappeared.  For  two  months  patient  remained  in  the  same  state.  As  long  as 
she  was  in  the  recumbent  position  she  felt  pretty  comfortable  ;  but  any  attempt  at  sitting  up  in 
bed,  or  any  unusual  exertion,  immediately  brought  on  the  embarrassed  respiration.  During  all 
this  time  it  was  found  necessary  to  administer  stimulants  profusely  to  ward  off  the  attacks.  Event- 
ually the  patient  recovered  completely. 

Q.  F.,  aged  forty-four  years.  Mother  of  twelve  children.  Confined  on  July  6th.  On  the  eleventh 
day  she  went  to  bed  feeling  well.  There  was  no  swelling  or  discomfort  of  any  kind  about  the 
lower  extremities  at  this  time.  About  3.30  A.M.  she  was  sitting  up  in  bed,  when  she  was  suddenly 
attacked  with  an  indescribable  sense  of  oppression  in  the  chest,  and  fell  back  in  a  semi-unconscious 
state,  gasping  for  breath.  She  remained  in  a  very  critical  condition,  with  the  same  symptoms  of 
embarrassed  respiration,  for  three  days,  when  they  gradually  passed  away.  Two  days  after  the 
attack  phlegmasia  doleus  came  on,  the  leg  swelled,  and  remained  so  for  several  months. 

This  case  is  an  example  of  the  fact  I  have  already  referred  to, 
of  phlegmasia  dolens  coming  on  after  the  symptoms  of  pulmonary 
obstruction  had  manifested  themselves ;  the  inference  being  that  both 
depended  on  similar  causes  operating  on  two  distinct  parts  of  the 
circulatory  system.1 

C.  H.,  aged  twenty-four  years.  Confined  of  her  first  child  on  August  20, 1867.  Thirty  hours  after 
delivery  she  complained  of  great  weakness  and  dyspnoea.  This  was  alleviated  by  the  treatment 
employed,  but  on  the  ninth  day,  after  making  a  sudden  exertion,  the  dyspncea  returned  with  in- 
creased violence,  and  continued  unabated  until  I  saw  the  patient  on  September  4th,  fourteen  days 
after  her  confinement.  The  following  are  the  notes  of  her  condition,  made  at  the  time  of  her 
visit:  "I  found  her  sitting  on  the  sofa,  propped  up  with  pillows,  as  she  said  she  could  not 
breathe  In  the  recumbent  position.  The  least  excitement  or  talking  brought  on  the  most  aggra- 
vated dyspmwi,  which  was  so  bad  as  to  threaten  almost  instant  death.  Her  sufferings  during  these 
paroxysms  were  terrible  to  witness.  She  panted  and  struggled  for  breath,  and  her  chest  heaved 
with  short  gasping  respirations.  She  could  not  even  bear  anyone  to  stand  in  front  of  her,  waving 
them  away  with  her  hand,  and  calling  for  more  air.  These  attacks  were  very  frequent,  and  were 
brought  on  by  the  most  trivial  causes.  She  talked  in  a  low,  suppressed  voice,  as  if  she  could  not 
spare  breath  for  articulation.  On  auscultation  air  was  found  to  enter  the  lungs  freely  in  every 
direction  both  in  front  and  behind.  Immediately  over  the  site  of  the  pulmonary  arteries  there 
was  a  distinct  harsh,  rasping  murmur,  confined  to  a  very  limited  space,  and  not  propagated  either 
upward  or  down  ward.  The  heart-sounds  were  feeble  and  tumultuous."  These  symptoms  led  me 
to  diagnose  pulmonary  obstruction,  and  I  of  course  gave  a  most  unfavorable  prognosis,  but  to 
my  great  surprise  the  patient  slowly  recovered.  I  saw  her  again  six  weeks  later,  when  her  heart- 
sounds  were  regular  and  distinct  and  the  murmur  had  completely  disappeared. 


of  Bristol 

symptoms  of  piilmuimiv  uk/on  uvm/i.*  \*»*  «*«•»«***»•.  .7  — -i  -— -,  . "?~  ."•'r 

fined  on  the  27th,  her  condition  from  apiuea  being  then  so  critical  that  death  was  momentarily 
expected  Thirty  hours  after  delivery  symptoms  of  phlegmasia  dolens,  with  painful  swelling  of 
both  legs  and  thighs,  occurred.  After  a  protracted  illness  tlie  patient  gradually  recovered  This 
case  is  of  special  interest,  since  the  symptoms  of  pulmonary  obstruction  occurred  before  delivery. 
The  only  other  instance  of  the  same  kind  I  know  of  has  been  recently  recorded  by  Dr.  Church 
—  vol.  xvii.  p.  211),  and  that  ended  fatally. 


664  THE    PUERPERAL    STATE. 

E.  E.,  aged  forty-two  years,  was  confined  for  the  first  time  on  November  5,  1873,  in  the  sixth 
month  of  utero-gestation.  She  had  severe  post-partum  hemorrhage,  depending  on  partially  ad- 
herent placenta,  which  was  removed  artificially.  She  did  perfectly  well  until  the  fourteenth"  day 
after  delivery,  when  she  was  suddenly  attacked  with  intense  dyspnoea,  aggravated  in  paroxysms. 
Pulse  pretty  full,  130,  but  distinctly  intermittent.  Air  entered  lungs  ireely,  The  heart's  action 
was  fluttering  and  irregular,  and  at  the  juncture  of  the  fourth  and  fifth  ribs  with  the  sternum 
there  was  a  loud  blowing  systolic  murmur.  This  was  certainly  non-existent  before,  as  the  heart 
had  been  carefully  auscultated  before  administering  chloroform  during  labor.  For  two  days  the 
patient  remained  in  the  same  state,  her  death  being  almost  momentarily  expected.  On  the  21st— 
that  is,  two  days  after  the  appearance  of  the  chest  symptoms — phlegmasia  dolens  of  a  severe  kind 
developed  itself  in  the  right  thigh  and  leg.  She  continued  in  the  same  state  for  many  days,  lying 
more  or  less  tranquilly,  but  having  paroxysms  of  the  most  intense  apncua,  varying  from  two  to 
six  or  eight  in  the  twenty-four  hours.  No  one  who  saw  her  in  one  of  these  could  have  expected 
her  to  live  through  it.  Shortly  after  the  first  appearance  of  the  paroxysms  it  was  observed  that 
the  cellular  tissue  of  the  neck  and  part  of  the  face  became  swollen  and  oedematous,  giving  an 
appearance  not  unlike  that  of  phlegmasia  dolens,  The  attacks  were  always  relieved  by  stimu- 
lants. These  she  incessantly  called  for,  declaring  that  she  felt  that  they  kept  her  alive.  During 
all  this  time  the  mind  was  clear  and  collected.  The  pulse  varied  from  110  to  130;  respirations 
about  60 ;  temperature  101°  to  102.5°.  By  slow  degrees  the  patient  seemed  to  be  rallying.  The 
paroxysms  diminished  in  number,  and  after  December  1st  she  never  had  another,  and  the  breath- 
ing be'came  Iree  and  easy.  The  pulse  fell  to  80,  and  the  cardiac  murmur  entirely  disappeared. 
The  patient  remained,  however,  very  weak  and  feeble,  and  the  debility  seemed  to  increase. 
Toward  the  second  week  in  December  she  became  delirious,  and  died,  apparently  exhausted, 
without  any  fresh  chest  symptoms,  on  the  19th  of  that  mouth.  No  post-mortem  examination  was 
allowed. 

I  have  narrated  this  ease,  although  it  terminated  fatally,  because  I 
hold  it  to  be  one  of  the  class  I  am  considering.  The  death  was  cer- 
tainly not  due  to  the  obstruction,  all  symptoms  of  which  had  disap- 
peared, but  apparently  to  exhaustion  from  the  severity  of  the  former 
illness.  It  illustrates,  too,  the  simultaneous  appearance  of  symptoms 
of  pulmonary  obstruction  and  peripheral  thrombosis.  The  swelling 
of  the  neck  was  a  curious  symptom,  which  has  not  been  recorded  in 
any  other  cases,  and  may  possibly  be  a  further  proof  of  the  analogy 
between  this  condition  and  phlegmasia  doleus. 

Such  Cases  can  only  Depend  on  Pulmonary  Obstruction. — 
Now  it  may,  of  course,  be  argued  that  these  cases  do  not  prove  my 
thesis,  inasmuch  as  I  only  assume  the  presence  of  a  coagulum.  But 
I  may  fairly  ask  in  return,  What  other  condition  could  possibly  explain 
the  symptoms  ?  They  are  precisely  those  which  are  noticed  in  death 
from  undoubted  pulmonary  obstruction.  Xo  one  seeing  one  of  them, 
or  even  reading  an  account  of  the  symptoms,  while  ignorant  of  the 
result,  could  hesitate  a  single  instant  in  the  diagnosis.  Surely,  then, 
the  inference  is  fair  that  they  depended  on  the  same  cause.  In  the 
very  nature  of  things  my  hypothesis  cannot  be  verified  by  post-mortem 
examination ;  but  there  is  at  least  one  case  on  record  in  which,  after 
similar  symptoms,  a  clot  was  actually  found.  The  case  is  related  by 
Dr.  Richardson.1  It  was  that  of  a  man  who  for  weeks  had  symptoms 
precisely  similar  to  those  observed  in  the  cases  I  have  narrated.  In 
one  of  his  agonizing  struggles  for  breath  he  died,  and  after  death  it 
was  found  "  that  a  fibrinous  band,  having  its  hold  in  the  ventricle, 
extended  into  the  pulmonary  artery."  This  observation  proves  to  a 
certainty  that  life  may  continue  for  weeks  after  the  depositing  of 
a  coagulum ;  and,  moreover,  this  condition  .was  precisely  what  we 
should  anticipate,  since,  of  course,  the  obstructing  coagulum  must 
necessarily  be  small,  otherwise  the  vital  functions  woulcj  be  imme- 
diately arrested. 

Cardiac  Murmurs  in  Pulmonary  Obstruction. — There  is  a 
symptom  noted  in  two  of  the  above  cases,  and  to  a  less  extent  in  a 

1  Clinical  Essays,  p.  224  et  seq. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.      665 

third,  which  has  not  been  mentioned  iii  any  account  of  fatal  cases 
occurring  after  delivery,  viz.,  a  murmur  over  the  site  of  the  pulmonary 
arteries.  It  is  a  sign  we  should  naturally  expect,  and  very  possibly  it 
would  be  met  with  in  fatal  cases  if  attention  were  particularly  directed 
to  the  point.  In  both  these  instances  it  was  exceedingly  well  marked, 
and  in  both  it  entirely  disappeared  when  the  symptoms  abated.  The 
probability  of  such  a  murmur  being  audible  in  cases  of  thrombosis  of 
the  pulmonary  artery  has  been  recognized  by  one  of  our  highest 
authorities  in  cardiac  disease,  who  actually  observed  it  in  a  non- 
puerperal  case.  In  the  last  edition  of  his  work  on  diseases  of  the 
heart,  Dr.  Walshe1  says:  "The  only  physical  condition  connected 
with  the  vessel  itself  would  probably  be  systolic  basic  murmur  follow- 
ing the  course  of  the  pulmonary  main  trunk  and  of  its  immediate 
divisions  to  the  left  and  right  of  the  sternum.  This  sign  I  most  cer- 
tainly heard  in  an  old  gentleman  whose  life  was  brought  to  a  sudden 
close  in  the  course  of  an  acute  affection  by  coagulation  in  the  pulmonary 
artery,  and  to  a  moderate  extent  in  the  right  ventricle. 

Similar  cases  have,  probably,  been  overlooked  or  misinterpreted. 
Many  seem  to  have  been  attributed  to  shock,  in  the  absence  of  a  better 
explanation,  a  condition  to  which  they  bear  no  kind  of  resemblance. 

Causes  of  Death. — The  precise  mode  of  death  in  pulmonary  ob- 
struction, whether  dependent  on  thrombosis  or  embolism,  has  given 
rise  to  considerable  difference  of  opinion.  Virchow  attributes  it  to 
syncope,2  depending  on  stoppage  of  the  cardiac  contraction.  Panum,3 
on  the  other  hand,  contests  this  view,  maintaining  that  the  heart  con- 
tinues to  beat  even  after  all  signs  of  life  have  ceased.  Certainly 
tumultuous  and  irregular  pulsations  of  the  heart  are  prominent  symp- 
toms in  most  of  the  recorded  cases,  and  are  not  reconcilable  with  the 
idea  of  syncope.  Panum's  own  theory  is  that  death  is  the  result  of 
cerebral  anaemia.  Paget  seems  to  think  that  the  mode  of  death  is 
altogether  peculiar,  in  some  respects  resembling  syncope,  in  others 
ana'iiiia.  Bertin,  who  has  discussed  the  subject  at  great  length, 
attributes  the  fatal  result  purely  to  asphyxia.  The  condition,  indeed,  is 
in  all  respects  similar  to  that  state,  the  oxygenation  of  the  blood  being 
prevented,  not  because  air  cannot  get  to  the  blood,  but  because  blood 
cannot  get  to  the  air.  The  symptoms  also  seem  best  explained  by  this 
theory  ;  the  intense  dyspnoea,  the  terrible  struggle  for  air,  the  preserva- 
tion of  intelligence,  the  tumultuous  action  of  the  heart,  are  certainly 
not  characteristic  either  of  syncope  or  anaemia. 

Post-mortem  Appearances  of  Clots. — The  anatomical  character 
of  the  clots  seems  to  vary  considerably.  Ball,  by  whom  they  have 
been  most  carefully  described,  believes  that  they  generally  commence 
in  the  smaller  ramifications  of  the  arteries," extending  backward  toward 
the  heart,  and  filling  the  vessels  more  or  less  completely.  Toward  its 
cardiac  extremity  the  coagulum  terminates  in  a  rounded  head,  in  which 
respect  it  resembles  those  spontaneously  formed  in  the  peripheral 
veins.  It  is  non-adherent  to  the  coats  of  the  vessels,  and  the  blood 
circulates,  when  it  can  do  so  at  all,  between  it  and  the  vascular  walls. 

i  Walshe :  On  Diseases  of  the  Heart,  4th  ed.,  1873. 

»  Gesamm.  Abhaudl.,  1862,  p.  316.  Virchow's  Archiv,  1863 


666  THE    PUERPERAL    STATE. 

Such  clots  are  white,  dense,  and  of  a  homogeneous  structure,  consisting 
of  layers  of  decolorized  fibrin,  firm  at  the  periphery,  where  the  fibrin 
has  been  most  recently  deposited,  and  softened  in  the  centre  where 
amylaceous  or  fatty  degeneration  has  commenced.  Ball  maintains  that 
if  the  coagulum  have  commenced  in  the  larger  branches  of  the  arteries, 
it  must  have  first  begun  in  the  ventricle  and  extended  into  them. 
According  to  Humphry  the  same  changes  take  place  in  pulmonary  as 
in  peripheral  thrombi,  and  they  may  become  adherent  to  the  walls  of 
the  vessels  or  converted  into  threads  or  bands.  When  the  obstruction 
is  due  to  embolism,  provided  the  case  is  a  well-marked  one  and  the 
embolus  of  some  size,  the  appearances  presented  are  different.  We 
have  no  longer  a  laminated  and  decolorized  coagulum,  with  a  rounded 
head,  similar  to  a  peripheral  thrombus.  The  obstruction  in  this  case 
generally  takes  place  at  the -point  of  bifurcation  of  the  artery,  and  we 
there  meet  with  a  grayish-white  mass,  contrasting  remarkably  with 
the  more  recently  deposited  fibrin  before  and  behind  it.  It  may  be 
that  the  form  of  the  embolus  shows  that  it  has  recently  been  separated 
from  a  clot  elsewhere  ;  and  in  many  cases  it  has  been  possible  to  fit  the 
travelled  portion  to  the  extremity  of  the  clot  from  which  it  has  been 
broken.  We  may  also,  perhaps,  find  that  the  embolus  has  undergone 
an  amount  of  retrograde  metamorphosis  corresponding  with  that  of 
the  peripheral  thrombus  from  which  we  suppose  it  to  have  come,  but 
differing  from  that  of  the  more  recently  deposited  fibrin  around  it.  It 
must  be  admitted,  however,  that  the  anatomical  peculiarities  of  the 
coagula  will  by  no  means  always  enable  us  to  trace  them  to  their  true 
origin.  In  many  cases  emboli  may  escape  detection  from  their  small- 
ness  or  from  the  quantity  of  fibrin  surrounding  them. 

Treatment. — But  few  words  need  be  said  as  to  the  treatment  of 
pulmonary  obstruction.  In  a  large  majority  of  cases  the  fatal  result 
BO  rapidly  follows  the  appearance  of  the  symptoms  that  no  time  is 

fiven  us  even  to  make  an  attempt  to  alleviate  the  patient's  sufferings, 
hould  we  meet  with  a  case  not  immediately  fatal,  it  seems  that  there 
are  but  two  indications  of  treatment  affording  the  slightest  rational 
ground  of  hope. 

1 .  To  keep  the  patient  alive  by  the  administration  of  stimulants — 
brandy,  ether,  ammonia,  and  the  like — to  be  repeated  at  intervals  cor- 
responding to  the  intensity  of  the  paroxysms  and  the  results  produced. 
In  the  cases  I  have  above  narrated,  in  which  recovery  ensued,  this 
took  the  place  of  all  other  medication.     Possibly  leeches,  or  dry  cup- 
ping to  the  chest,  misrht  prove  of  some  service  in  relieving  the  circu- 
lation. 

2.  To  enjoin  the  most  absolute  and  complete  repose.     The  object  of 
this  is  evident.     The  only  chance  for  the  patient  seems  to  be  that  the 
vital   functions  should   be  carried   on  until   the  coagulum  has  been 
absorbed,  or  at  least  until  it  has  been  so  much  lessened  in  size  as  to 
admit  of  blood  passing  it  to  the  lungs.     The  slightest  movements  may 
give  rise  to  a  fatal  paroxysm  of  dyspnoea,  from  the  increased  supply  of 
oxygenated  blood  required.     It  must  not  be  forgotten  that  in  a  large 
proportion  of  cases  death  immediately  followed  some  exertion  in  itself 
trivial,  such  as  rising  out  of  bed.     Too  much  attention,  then,  cannot 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.      667 

be  given  to  this  point.  The  patient  should  be  kept  absolutely  still ; 
she  should  be  fed  with  abundance  of  fluid  food,  such  as  milk,  strong 
soups,  and  the  like ;  and  she  should  on  no  account  be  permitted  to 
raise  herself  in  bed,  or  attempt  the  slightest  muscular  exertion.  If  we 
are  fortunate  enough  to  meet  with  a  case  apparently  tending  to  recovery, 
these  precautions  must  be  carried  on  long  after  the  severity  of  the 
symptoms  has  lessened,  for  a  moment's  imprudence  may  suffice  to 
bring  them  back  in  all  their  original  intensity. 

Bertin,1  indeed,  recommends  a  system  of  treatment  very  different 
from  this.  In  the  vain  hope  that  the  violent  effort  induced  may  cause 
the  displacement  of  the  impacted  em  bolus  (to  which  alone  he  attributes 
pulmonary  obstruction),  he  recommends  the  administration  of  emetics. 
Few,  I  fancy,  will  be  found  bold  enough  to  attempt  so  hazardous  a 
plan  of  treatment. 

Various  drugs  have  been  suggested  in  these  cases.  Richardson2 
recommended  ammonia,  a  deficiency  of  which  he  at  that  time  believed 
to  be  the  chief  cause  of  coagulation.  He  has  since  advised  that  liquor 
ammonite  should  be  given  in  large  doses,  twenty  minims  every  hour, 
in  the  hope  of  causing  solution  of  the  deposited  fibrin ;  and  he  has 
stated  that  he  has  seen  good  results  from  the  practice.  Others  advise 
the  administration  of  alkalies,  in  the  hope  that  they  may  favor 
absorption.  The  best  that  can  be  said  for  them  is  that  they  are  not 
likely  to  do  much  harm.  The  inhalation  of  oxygen,  which  has  been 
used  with  great  success  in  severe  pneumonia,3  is  obviously  a  hopeful 
remedy  in  this  condition,  and  is  well  worthy  of  trial. 

Puerperal  Pleuro-pneumonia. — This  is,  perhaps,  the  best  place  to 
mention  an  important  but  little  understood  class  of  cases  which  I 
believe  to  be  less  uncommon  than  is  generally  supposed.  I  refer  to 
severe  pleuro-pneumonia  occurring  in  connection  with  the  puerperal 
state,  but  not  distinctly  associated  with  septicaemia.  Two  carefully 
observed  cases  of  this  kind  are  recorded  by  MacDonald,  occurring  in 
his  practice ;  I  myself  have  met  with  three  very  marked  examples 
within  the  past  three  years,  one  of  which  proved  fatal,  the  other  two 
giving  rise  to  most  serious  illness,  from  which  the  patient  recovered 
with  difficulty. 

So  far  as  my  own  observation  goes  there  are  marked  peculiarities  in 
such  cases  which  clearly  differentiate  them  from  the  ordinary  course  of 
pneumonia.  The  onset  is  sudden  and  unconnected  with  exposure  to 
cold  or  other  cause  of  lung  disease ;  there  is  no  definite  crisis,  but  a 
continuous  pyrexia  of  moderate  intensity  lasting  a  variable  time ;  and 
the  physical  signs  differ  from  those  of  ordinary  pneumonia. 

Physical  Signs. — In  MacDonald's  case,  as  well  as  in  my  own,  they 
were  peculiar  in  this  respect,  that  there  was  very  slight  ^  crepitation, 
marked  rusty  sputum,  and  a  wooden  dulness,  much  more  intense  than 
in  ordinary  pneumonia,  extending'over  a  large  lung  space,  with  a  very 
slight  entrance  of  air  into  the  lung  tissue.  It  is  also  remarkable  that 
a  very  large  proportion  of  the  cases  were  associated  with  phlegmasia 

1  Op.  cit.,  p.  393. 

s  Heart  Disease  during  Pregnancy,  p.  209. 

8  "On  the  Use  of  Oxygen  and  Strychnia  in  Pneumonia,"  Brit.  Med.  Journ.,  January  23, 1892. 


668  THE    PUERPERAL    STATE. 

dolens.  Thus  it  existed  in  one  of  MacDonald's  two  cases,  and  in  two 
out  of  my  own  three.  Like  phlegmasia  dolens,  moreover,  the  disease 
generally  commenced  some  weeks  after  delivery ;  my  own  cases,  for 
example,  occurred  respectively  fifteen,  twenty-eight,  and  thirty-five 
days  after  labor.  It  is  difficult  to  believe  that  there  is  not  some 
connection  between  these  two  conditions,  and  there  is  much  in  their 
peculiar  history  to  lead  to  the  belief  that  such  forms  of  lung  disease 
depend,  in  fact,  on  the  thrombotic  or  embolic  obstruction  of  the  minute 
branches  of  the  pulmonary  arteries,  caused  by  conditions  similar  to 
those  which  have  produced  the  phlebitic  obstructions  in  the  lower 
extremities.  In  the  absence  of  careful  post-mortem  examination  this 
hypothesis  is  clearly  not  susceptible  of  proof.  MacDonald,  while 
admitting  that  "  a  limited  thrombosis  of  the  pulmonary  arteries  would 
no  doubt  explain  the  facts  of  the  cases,"  is  rather  inclined  to  "  seek 
the  chief  explanation  of  their  occurrence  in  the  alterations  which  the 
pregnant  and  puerperal  conditions  impress  upon  the  blood  and  the 
blood-vascular  system." 

I  confess  that  to  my  mind  the  former  hypothesis  is  not  only  the 
most  definite,  but  the  one  which  most  readily  explains  all  the  pecu- 
liarities of  these  cases.  I  cannot,  however,  do  more  thau  suggest  it, 
in  the  hope  that  further  observations,  and  especially  carefully  con- 
ducted autopsies,  may  throw  some  light  on  this  obscure  and  little- 
studied  subject. 

Treatment. — As  regards  treatment,  it  is  obvious  that  it  must  be 
conducted  on  general  principles,  carefully  avoiding  over-severe  meas- 
ures, and  supporting  the  patient  through  a  trial  to  the  system  that 
must  necessarily  be  severe. 


CHAPTEE   VII. 

PUERPERAL  ARTERIAL  THROMBOSIS   AND   EMBOLISM. 

Arterial  Thrombosis  and  Embolism. — The  same  condition  of  the 
blood  which  so  strongly  predisposes  to  coagulation  in  the  vessels 
through  which  venous  blood  circulates  tends  to  similar  results  in  the 
arterial  system.  These,  however,  are  by  no  means  so  common,  and 
do  not,  as  a  rule,  lead  to  such  important  consequences.  The  subject 
has  been  but  little  studied,  and  almost  all  our  knowledge  of  it  is 
derived  from  a  very  interesting  essay  by  Sir  James  Simpson.1  As  I 
have  devoted  so  much  space  to  the  consideration  of  venous  thrombosis 
and  embolism,  I  shall  but  briefly  consider  the  effects  of  arterial  ob- 
struction. 

Causes. — In  a  considerable  number  of  recorded  cases  the  obstruc- 

1  Selected  Obstet.  Works,  vol.  i.  p.  523. 


PUERPERAL    ARTERIAL    THROMBOSIS    AND    EMBOLISM.      669 

tion  has  resulted  from  the  detachment  of  vegetations  deposited  on  the 
cardiac  valves,  the  result  of  endocarditis,  either  produced  by  antecedent 
rheumatism  or  as  a  complication  of  the  puerperal  state.  Sometimes 
the  obstruction  seems  to  depend  on  some  general  blood  dyscrasia, 
similar  to  that  producing  venous  thrombosis,  or  on  some  local  change 
in  the  artery  itself.  Thus  Simpson  records  a  case  apparently  produced 
by  local  arteritis,  which  caused  acute  gangrene  of  both  lower  extremi- 
ties, ending  fatally  in  the  third  week  after  delivery.  In  other  cases  it 
has  been  attributed  to  coagulation  following  spontaneous  laceration 
and  corrugation  of  the  internal  coat  of  the  artery. 

Symptoms. — The  symptoms  of  puerperal  arterial  obstruction  must, 
of  course,  vary  with  the  particular  arteries  affected.     Those  with  the 
obstruction  of  which  we  are  most  familiar  are  the  cerebral,  the  brachial, 
and  the  femoral.     The  effects  produced  must  also  be  modified  by  the 
size  of  the  embolus,  and  the  more  or  less  complete  obstruction  it  pro- 
duces.    Thus,  for  example,  if  the  middle  cerebral  artery  be  blocked 
up  entirely,  the  functions  of  those  portions  of  the  brain  supplied  by  it 
will  be  more  or  less  completely  arrested,  and  hemiplegia  of  the  oppo- 
site side  of  the  body,  followed  by  softening  of  the  brain  texture,  will 
probably  result.     If  the  nervous  symptoms  be  developed  gradually, 
or  increase  in  intensity  after  their  first  appearance,  it  may  be  that  an 
obstruction,  at  first  incomplete,  has  increased  by  the  deposition  of 
fibrin  around  it.     So  the  occasional  sudden  supervention  of  blindness, 
with   destruction  of  the   eyeball — cases  of  which   are   recorded   by 
Simpson — not  improbably  depend  on  the  occlusion  of  the  ophthalmic 
artery,  the  function  of  the  organ  depending  on  its  supply  through  the 
single  artery.     The  effects  of  obstruction  of  the  visceral  arteries  in 
the  puerperal  state  are  entirely  unknown,  but  it  is  far  from  unlikely 
that  further  investigation  may  prove  them  to  be  of  great  importance. 
In  the  extremities 'arterial  obstruction  produces  effects  which  are  well 
marked.     They  are  classified  by  Simpson  under  the  following  heads  : 
1.  Arrest  of  pulse  below  the  site  of  obstruction.     This  has  been  observed 
to  come  on  either  suddenly  or  gradually,  and,  if  the  occlusion  be  in 
one  of  the  large  arterial  trunks,  it  is  a  symptom  which  a  careful  ex- 
amination will  readily  enable  us  to  detect.      2.  Increased  force  of 
pulsation  in  the  arteries  above  the  seat  of  obstruction.     3.  Fall  in  the 
temperature  of  the  limb.    This  is  a  symptom  which  is  easily  appreciable 
by  the  thermometer,  and  when  the  "main  artery  of  the  limb  is  occluded 
the  coldness  of  the  extremity  is  well  marked.     4.  Lesions  of  motor 
and  sensory  functions,  paralysis,  neuralgia,  etc.      Loss  of  power  in 
the  affected  limb  is  often  a  prominent  symptom,  and  when  it  comes 
on  suddenly,   and    is   complete,   the    main    artery  will    probably   be 
occluded.     It  may  be  diagnosed  from  paralysis  depending  on  cerebral 
or  spinal  causes  by  the  absence  of  head  symptoms,  by  the  history  of 
the  attack,  and  by  the  presence  of  other  indications  of  arterial  obstruc- 
tion, such  as  loss  of  pulsation  in  the  artery,  fall  of  temperature,  etc. 
The  sensory  functions  in  these  cases  are  generally  also  seriously  dis- 
turbed, not  so  much  by  loss  of  sensation  as  by  severe  pain  and  neur- 
algia.    Sometimes  the  pain  has  been  excessive,  and  occasionally  it  has 
been  the  first  symptom  which  directed  attention  to  the  state  of  the 


670  THE    PUERPERAL    STATE. 

limb.  5.  Gangrene  below  or  beyond  the  seat  of  arterial  obstruction. 
Several  interesting  cases  are  recorded  in  which  gangrene  has  followed 
arterial  obstruction.  Generally  speaking,  gangrene  will  not  follow 
occlusion  of  the  main  arterial  trunk  of  an  extremity,  as  the  collateral 
circulation  soon  becomes  sufficiently  developed  to  maintain  its  vitality. 
In  many  of  the  cases  either  thrombi  have  obstructed  the  channels  of 
collateral  circulation  as  well,  or  the  veins  of  the  limb  have  also  been 
blocked  up.  When  such  extensive  obstructions  occur,  they  obviously 
cannot  be  embolic,  but  must  depend  on  a  local  thrombosis,  traceable 
to  some  general  blood  dyscrasia  depending  on  the  puerperal  state. 

Treatment.  — Little  can  be  said  as  to  the  treatment  of  such  cases, 
which  must  vary  with  the  gravity  and  nature  of  the  symptoms  in 
each.  Beyond  absolute  rest  (in  the  hope  of  eventual  absorption  of  the 
thrombus  or  embolus),  generous  diet,  attention  to  the  general  health 
cf  the  patient,  and  sedative  applications  to  relieve  the  local  pain,  there 
is  little  in  our  power.  Should  gangrene  of  an  extremity  supervene  in 
a  puerperal  patient,  the  case  must  necessarily  be  well-nigh  hopeless. 
Simpson,  however,  records  one  instance  in  which  amputation  was  per- 
formed above  the  line  of  demarcation,  the  patient  eventually  recovering. 


CHAPTER    Till. 

OTHER  CAUSES  OF  SUDDEN   DEATH   DURING  LABOR  AND 
THE  PUERPERAL  STATE. 

A  LARGE  number  of  the  cases  in  which  sudden  death  occurs  during 
or  after  delivery  find  their  explanation,  as  I  have  already  pointed  out, 
in  thrombosis  or  embolism  of  the  heart  and  pulmonary  arteries. 
Probably  many  cases  of  the  so-called  idiopathic  asphyxia  were,  in  fact, 
examples  of  this  accident,  the  true  nature  of  which  had  been  mis- 
understood. Besides  these,  there  are,  no  doubt,  many  other  condi- 
tions which  may  lead  to  a  suddenly  fatal  result  in  connection  with 
parturition. 

Some  of  these  are  of  an  organic,  others  of  a  functional  nature. 

Organic  Causes. — Among  the  former  may  be  mentioned  cases  in 
which  the  straining  efforts  of  the  second  stage  of  labor  have  produced 
death  in  patients  suffering  from  some  pre-existent  disease  of  the  heart. 
Rupture  of  that  organ  has  probably  occurred  from  fatty  degeneration 
of  its  walls.  Dehous l  narrates  an  instance  in  which  the  efforts  of 
labor  caused  the  rupture  of  an  aneurism.  Another  case,  from  inter- 
ference with  the  action  of  the  heart  in  a  patient  who  had  pericardial 
effusion,  is  narrated  by  Ramsbotham.  Dr.  Devilliers  relates  an 

1  Dehous :  Sur  les  Morts  subites. 


CAUSES    OF    SUDDEN    DEATH    DURING    LABOR.  671 

instance  occurring  in  a  young  woman  during  the  second  stage  of 
labor.  The  heart  was  found  to  be  healthy,  but  the  lungs  were  in- 
tensely congested  and  blood  was  extensively  extravasated  all  through 
their  texture.  This  was  probably  caused  by  pulmonary  congestion 
and  apoplexy,  produced  by  the  severe  straining  efforts.  "  Many  cases 
from  effusion  of  blood  into  the  brain  substance,  or  on  its  surface,  are 
on  record — no  doubt  in  patients  who,  from  arterial  degeneration  or 
other  causes,  were  predisposed  to  apoplectic  effusions.  The  so-called 
apoplectic  convulsions,  formerly  described  in  most  works  on  obstetrics 
as  a  variety  of  puerperal  convulsions,  are  evidently  nothing  more  than 
apoplexy  coming  on  during  or  after  labor.  As  regards  their  path- 
ology, they  do  not  seem  to  differ  from  ordinary  cases  of  apoplexy  in 
the  non-pregnant  condition.  One  example  is  recorded  of  death  which 
wras  attributed  to  rupture  of  the  diaphragm  from  excessive  action  in 
the  second  stage. 

Functional  Causes. — Among  the  causes  of  death  which  cannot  be 
traced  to  some  distinct  organic  lesion  may  be  classed  cases  of  syncope, 
shock,  and  exhaustion.  Many  instances  of  this  kind  are  recorded. 
Thus  in  some  women  of  susceptible  nervous  organization  the  severity  of 
the  suffering  appears  to  bring  on  a  condition  similar  to  that  produced 
by  excessive  shock  or  exhaustion,  which  has  not  unfrequently  proved 
fatal.  Several  examples  of  this  kind  have  been  cited-  by  McClintock.1 
It  is  also  not  unlikely  that  sudden  syncope  sometimes  produces  a  fatal 
result  during  or  after  labor.  Most  cases  of  death  otherwise  inex- 
plicable used  to  be  referred  to  this  cause ;  but  accurate  autopsies 
were  seldom  made,  and  even  when  they  were — the  important  effects  of 
pulmonary  coagula  being  unknown — it  is  more  than  probable  that  the 
true  cause  of  death  was  overlooked.  It  has  been  supposed  that  the 
sudden  removal  of  pressure  from  the  veins  of  the  abdomen,  by  the 
emptying  of  the  gravid  uterus  after  delivery,  may  favor  an  increased 
afflux  of  blood  into  the  lower  parts  of  the  body,  and  thus  tend  to  an 
anaemic  condition  of  the  brain  and  the  production  of  syncope.  How- 
ever this  may  be,  the  possibility  of  its  occurrence,  and  its  manifest 
danger  in  a  recently  delivered  womau,  are  sufficient  reasons  for  en- 
forcing the  recumbent  position  after  labor  is  over.  In  some  of  the 
cases  the  syncope  was  evidently  produced  by  the  patient  suddenly 
sitting  upright. 

Death  from  Air  in  the  Veins. — Some  cases  of  sudden  death  imme- 
diately after  labor  seem  to  be  due  to  the  entrance  of  air  into  the  veins. 
Six  examples  are  cited  by  McClintock  which  were  probably  due  to 
this  cause.  La  Chapelle  related  two.  An  interesting  ease  is  related 
by  M.  Lionet.2  In  this  the  patient  died  five  and  a  half  hours  after 
aii  easy  and  natural  labor,  the  chief  symptoms  being  extreme  pallor, 
efforts  "at  vomiting,  and  dyspnoea.  Air  was  found  in  the  heart  and  in 
the  arachnoid  veins.  There  can  be  no  question  that  the  uterine 
sinuses  after  delivery  are  nearly  as  well  adapted  as  the  veins  of  the 
neck  for  allowing  the  entrance  of  air.  They  are  firmly  attached  to 
the  muscular  walls  of  the  uterus,  so  that  they  gape  open  when  that 

i  Union  Med.,  1853.  2  Debous  :  op.  cit.,  p.  58. 


672  THE    PUERPERAL    STATE. 

organ  is  relaxed,  and  it  is  easy  to  understand  how  air  might  enter. 
Indeed,  in  the  post-mortem  examination  in  one  of  the  cases  occurring 
in  the  practice  of  Mme.  La  Chapelle,  it  is  stated  that  "  the  uterine 
sinuses  opened  in  the  interior  of  the  uterus  by  large  orifices  (one  line 
and  a  half  in  diameter),  through  which  air  could  readily  be  blown  as 
far  as  the  iliac  veins,  and  vice  versa."  The  condition  of  the  uterus 
after  delivery  also  enables  the  air  to  have  ready  access  to  the  mouths 
of  the  sinuses,  for  the  alternate  relaxation  and  contraction  of  the  uterus, 
occurring  after  the  placenta  is  expelled,  would  tend  to  draw  in  the  air 
as  by  a  suction-pump.  Hence  an  additional  reason  for  insisting  on 
firm  contraction  of  the  uterus,  as  this  will  lessen  the  risk  of  this 
accident. 

The  precise  mechanism  of  death  from  air  in  the  veins  has  been  a 
subject  of  dispute  among  pathologists.  By  Bichat1  it  was  referred  to 
anaemia  and  syncope  for  want  of  blood  in  the  vessels  of  the  brain, 
which  are  occupied  by  air.  Nysten2  attributed  it  to  distention  of  the 
cavities  of  the  heart  by  rarefied  air,  producing  paralysis  of  its  wall ; 
Leroy,  to  a  stoppage  of  the  pulmonary  circulation  and  consequent 
want  of  proper  blood-supply  to  the  left  heart ;  while  Leroy  d'Etoilles 
thought  it  might  depend  on  any  of  these  causes  or  a  combination  of 
all  of  them.  These,  and  many  other  hypotheses  on  the  subject,  have 
been  advanced,  to  all  of  which  serious  objection  could  be  raised.  The 
most  recent  theory  is  one  maintained  by  Virchow  and  Oppolzer,3  and 
more  recently  by  Feltz,  which  attributes  the  fatal  results  to  impaction 
of  the  air-globules  in  the  lesser  divisions  of  the  pulmonary  arteries, 
where  they  form  gaseous  emboli,  and  cause  death  exactly  in  the  same 
way  as  when  the  obstruction  depends  on  a  fibrinous  embolus.  The 
symptoms  observed  in  fatal  cases  closely  correspond  to  those  of  pul- 
monary obstruction,  and  it  is  not  unlikely  that  some  cases  attributed 
to  other  causes,  may 'really  depend  on  the  entrance  of  air  through  the 
uterine  sinuses.  Such,  for  example,  was  most  probably  the  explana- 
tion of  a  case  referred  to  by  Dr.  Graily  Hewitt  in  a  discussion  at  the 
Obstetrical  Society.*  Death  occurred  shortly  after  the  removal  of  an 
adherent  placenta,  during  which,  no  doubt,  air  could  readily  enter  the 
uterine  cavity.  The  symptoms,  viz.,  "  severe  pain  in  the  cardiac 
region,  distress  as  regards  respiration,  and  pulselessness,"  are  identical 
with  those  of  pulmonary  obstruction.  Dr.  Hewitt  refers  the  death  to 
shock,  which  Certainly  does  not  generally  produce  such  phenomena. 

1  Recherches  sur  la  Vie  et  la  Mort,  1853. 

2  Recherches  de  Phys.  et  Chim.  Path.,  1811. 

3  Kasuistik  der  Embolien  ;  Wiener  med.  Wochenschr.,  1862 ;  Des  Embolies  capillaires,  1868    and 
op.  cit.,  p.  115. 

«  Obst.  Trans.,  1869,  vol.  x.  p.  28. 


PERIPHERAL    VENOUS    THROMBOSIS.  673 


CHAPTER    IX. 

PERIPHERAL  VENOUS  THROMBOSIS— (SYN.  :  CRURAL  PHLEBITIS 

— PHLEGMASIA  DOLENS— ANASARCA  SEROSA— (EDEMA 

LACTEUM— WHITE  LEG,  ETC.). 

Peripheral  Thrombosis. — We  now  come  to  discuss  the  symptoms 
and  pathology  of  the  conditions  associated  with  the  formation  of 
thrombi  in  the  peripheral  venous  system,  or  rather  in  the  veins  of  the 
lower  extremities,  since  too  little  is  known  of  their  occurrence  in  other 
parts  to  enable  us  to  say  anything  on  the  subject.  •  <-.*-,<v 

The  most  important  of  these  is  the  well-known  disease  which,  under 
the  name  of  phlegmasia  dolens,  has  attracted  much  attention  and  given 
rise  to  numerous  theories  as  to  its  nature  and  pathology.  In  describing 
it  as  a  local  manifestation  of  a  general  blood  dyscrasia,  and  not  as  an 
essential  local  disease,  I  am  making  an  assumption  as  to  its  pathology 
that  many  eminent  authorities  would  not  consider  justifiable.  I  have, 
however,  already  stated  some  of  the  reasons  for  so  doing,  and  I  hope 
to  show  shortly  that  this  view  is  not  incompatible  with  the  most 
probable  explanation  of  the  peculiar  state  of  the  affected  limb. 

Symptoms. — The  first  symptom  which  usually  attracts  attention  is 
severe  pain  in  some  part  of  the  limb  that  is  about  to  be  affected.  The 
character  of  the  pain  varies  in  different  cases.  In  some  it  is  extremely 
acute,  and  is  most  felt  in  the  neighborhood  of,  and  along  the  course  of, 
the  chief  venous  trunks.  It  may  begin  in  the  groin  or  hip  and  extend 
downward;  or  it  may  commence  in  the  calf  and  proceed  upward  toward 
the  pelvis.  The  pain  abates  somewhat  after  swelling  of  the  limb 
(which  generally  begins  within  twenty-four  hours),  but  it  is  always  a 
distressing  symptom,  and  continues  as  long  as  the  acute  stage  of  the 
disease  lasts.  The  restlessness,  want  of  sleep,  and  suffering  which  it 
produces  are  sometimes  excessive.  Coincident  with  the  pain,  and 
sometimes  preceding  it,  more  or  less  malaise  is  experienced.  The 
patient  may  for  a  day  or  two  be  restless,  irritable,  and  out  of  sorts, 
without  any  very  definite  cause ;  or  the  disease  may  be  ushered  in  by 
a  distinct  rigor.  Generally  there  is  constitutional  disturbance,  varying 
with  the  intensity  of  the  case.  The  pulse  is  rapid  and  weak,  120  or 
thereabouts;  the  temperature  elevated  from  101°  to  102°,  with  an 
evening  exacerbation.  The  patient  is  thirsty ;  the  tongue  is  glazed  or 
white  and  loaded ;  the  bowels  constipated.  In  some  few  cases,  when 
the  local  affection  is  slight,  none  of  these  constitutional  symptoms  are 
observed. 

Condition  ol  the  Affected  Limb. — The  characteristic  swelling 
rapidly  follows  the  commencement  of  the  symptoms.  It  generally 
begins  in  the  groin,  whence  it  extends  downward.  It  may  be  limited 

43 


674  THE    PUERPERAL    STATE. 

to  the  thigh ;  or  the  whole  limb,  even  to  the  feet,  may  be  implicated. 
More  rarely  it  commences  in  the  calf  of  the  leg,  extending  upward  to 
the  thigh  and  downward  to  the  feet.  The  affected  parts  have  a  peculiar 
appearance  which  is  pathognomonic  of  the  disease.  They  are  hard, 
tense,  and  brawny  ;  of  a  shiny  white  color ;  and  not  yielding  on  press- 
ure, except  toward  the  beginning  and  end  of  the  illness.  The  appear- 
ances presented  are  quite  different  from  those  of  ordinary  oedema. 
When  the  whole  thigh  is  affected  the  limb  is  enormously  increased 
in  size.  Frequently  the  venous  trunks,  especially  the  femoral  and 
popliteal  veins,  are  felt  obstructed  with  coagula,  and  rolling  under  the 
finger.  They  are  painful  when  handled,  and  in  their  course  more  or 
less  redness  is  occasionally  observed.  Either  leg  may  be  attacked,  but 
the  left  more  frequently  than  the  right.  There  is  a  marked  tendency 
for  the  disease  to  spread,  and  we  often  find,  in  a  case  which  is  progress- 
ing apparently  well,  a  rise  of  temperature  and  an  accession  of  febrile 
symptoms  followed  by  the  swelling  of  the  other  limb. 

Progress  of  the  Disease. — After  the  acute  stage  has  lasted  from  a 
week  to  a  fortnight  the  constitutional  disturbance  becomes  less  marked, 
the  pulse  and  temperature  fall,  the  pain  abates,  and  the  sleeplessness 
and  restlessness  are  less.  The  swelling  and  tension  of  the  limb  now 
begin  to  diminish  and  absorption  commences.  This  is  invariably  a 
slow  process.  It  is  always  many  weeks  before  the  effusion  has  disap- 
peared, and  it  may  be  many  months.  The  limb  retains  for  a  length  of 
time  the  peculiar  wooden  feeling,  as  Dr.  Churchill  terms  it.  Any  im- 
prudence, such  as  a  too  early  attempt  at  walking,  may  bring  on  a 
relapse  and  fresh  swelling  of  the  limb.  This  gradual  recovery  is  by 
far  the  most  common  termination  of  the  disease.  In  some  rare  cases 
suppuration  may  take  place  either  in  the  subcutaneous  cellular  tissue, 
the  lymphatic  glands,  or  even  in  the  joints,  and  death  may  result  from 
exhaustion.  The  possibility  of  pulmonary  obstruction  and  sudden 
death  from  separation  of  an  embolus  have  already  been  pointed  out, 
and  the  fact  that  this  lamentable  occurrence  has  generally  followed 
some  undue  exertion  should  be  borne  in  mind  as  a  guide  in  the  man- 
agement of  our  patient. 

Period  of  Commencement. — The  disease  usually  begins  within  a 
short  time  after  delivery,  rarely  before  the  second  week.  In  22 
cases  tabulated  by  Dr.  Kobert  Lee,  7  were  attacked  between  the 
fourth  and  twelfth  days,  and  14  after  the  second  week.  Some  cases 
have  been  described  as  commencing  even  months  after  delivery.  It  is 
questionable  if  these  can  be  classed  as  puerperal,  for  it  must  not  be 
forgotten  that  phlegmasia  dolens  is  by  no  means  necessarily  a  puerperal 
disease.  There  are  many  other  conditions  which  may  give  rise  to  it,  all 
of  them,  however,  such  as  produce  a  septic  and  hyperinosed  state  of  the 
blood,  such  as  malignant  disease,  dysentery,  phthisis,  and  the  like.  My 
own  experience  wrould  lead  me  to  think  that  cases  of  this  kind  are 
much  more  common  than  is  generally  believed. 

History  and  Pathology. — The  disease  has  long  attracted  the  atten- 
tion of  the  profession.  Passing  over  more  or  less  obscure  notices  by 
Hippocrates,  De  Castro,  and  others,  we  find  the  first  clear  account  in 
the  writings  of  Mauriceau,  who  not  only  gave  a  very  accurate  de- 


PERIPHERAL    VENOUS    THROMBOSIS.  675 

seription  of  its  symptoms,  but  made  a  guess  at  its  pathology,  which 
was  certainly  more  happy  than  the  speculations  of  his  successors ;  it 
is,  he  says,  caused  "  by  a  reflux  on  the  parts  of  certain  humors  which 
ought  to  have  been  evacuated  by  the  lochia."  Puzos  ascribed  it  to  thd 
arrest  of  the  secretion  of  milk,  and  its  extravasation  in  the  affected 
limb.  This  theory,  adopted  by  Levret  and  many  subsequent  writers, 
took  a  strong  hold  011  both  professional  and  public  opinions,  and  to  it 
we  owe  many  of  the  names  by  which  the  disease  is  known  to  this  day, 
such  as  oedema  lacteum,  milk  leg,  ete.  In  1784  Mr.  White,  of  Man- 
chester, attributed  it  to  some  morbid  condition  of  the  lymphatic  glands 
and  vessels  of  the  affected  parts ;  and  this  or  some  analogous  theory, 
such  as  that  of  rupture  of  the  lymphatics  crossing  the  pelvic  brim,  as 
maintained  by  Tyre,  of  Gloucester,  or  general  inflammation  of  the 
absorbents,  as  held  by  Dr.  Ferrier,  was  generally  adopted. 

It  was  not  until  the  year  1823  that  attention  was  drawn  to  the  con- 
dition of  the  veins.  To  Bouillaud  belongs  the  undoubted  merit  of 
first  pointing  out  that  the  veins  of  the  affected  limb  were  blocked  up 
by  coagula,  although  the  fact  had  been  previously  observed  by  Dr. 
Davis,  of  University  College.  Dr.  Davis  made  dissections  of  the  veins 
in  a  fatal  case,  and  found,  as  Bouillaud  had  done,  that  they  were  filled 
with  coagula,  which  he  assumed  to  be  the  results  of  inflammation  of 
their  coats ;  hence  the  name  of  crural  phlebitis,  which  has  been  exten- 
sively adopted,  instead  of  phlegmasia  dolens.  Dr.  Robert  Lee  did 
much  to  favor  this  view  ;  and  finding  that  thrombi  were  present  in  the 
iliac  and  uterine,  as  well  as  in  the  femoral,  veins,  he  concluded  that 
the  phlebitis  commenced  in  the  uterine  branches  of  the  hypogastric 
veins  and  extended  dowmvard  to  the  femorals.  He  pointed  out  that 
phlegmasia  dolens  was  not  limited  to  the  puerperal  state ;  but  that 
when  it  did  occur  independently  of  it,  other  causes  of  uterine  phlebitis 
were  present,  such  as  cancer  of  the  os  and  cervix  uteri.  The  inflam- 
matory theory  was  pretty  generally  received,  and  even  now  is  con- 
sidered by  many  to  be  a  sufficient  explanation  of  the  disease.  Indeed, 
the  fact  that  more  or  less  thrombosis  was  always  present  could  not  be 
denied  ;  and  on  the  supposition  that  thrombosis  could  only  be  caused 
by  phlebitis,  as  was  long  supposed  to  be  the  case,  the  inflammatory 
theory  was  the  natural  one.  Before  long,  however,  pathologists  pointed 
out  that  thrombosis  was  by  no  means  necessarily  or  even  generally  the 
result  of  inflammation  of  the  vessels  in  which  the  clot  was  contained, 
but  that  the  inflammation  was  more  generally  the  result  of  the 
eoagulum. 

The  late  Dr.  Mackenzie  took  a  prominent  part  in  opposing  the 
phlebitic  theory.  He  proved  by  numerous  experiments  on  the  lower 
animals  that  inflammation  is  not  sufficient  of  itself  to  produce  the  ex- 
tensive thrombi  which  are  found  to  exist,  and  that  inflammation 
originating  in  one  part  of  a  vein  is  not  apt  to  spread  along  its  canal, 
as  the  phlebitic  theory-assumes.  His  conclusion  is  that  the  origin  of 
the  disease  is  rather  to  be  sought  in  some  septic  or  altered  condition  of 
the  blood,  producing  coagulation  in  the  veins.  Dr.  Tyler  Smith 

i  Tyler  Smith  :  Manual  of  Obstetrics,  p.  538. 


676  THE    PUERPERAL    STATE. 

pointed  out  an  occasional  analogy  between  the  causes  of  phlegmasia 
dolens  and  puerperal  fever,  evidently  recognizing  the  dependence  of 
the  former  on  blood  dyscrasia.  "  I  believe,"  he  says,  "  that  contagion 
and  infection  play  a  very  important  part  in  the  production  of  the 
disease.  I  look  on  a  woman  attacked  with  phlegmasia  dolens  as 
having  made  a  fortunate  escape  from  the  greater  dangers  of  diffuse 
phlebitis  or  puerperal  fever."  In  illustration  of  this  he  narrates  the 
following  instructive  history:  "A  short  time  ago  a  friend  of  mine  had 
been  in  close  attendance  on  a  patient  dying  of  ervsipelatous  sore-throat 
with  sloughing,  and  was  himself  affected  with  sore-throat.  Under 
these  circumstances  he  attended,  within  the  space  of  twenty-four  hours, 
three  ladies  in  their  confinements,  all  of  whom  were  attacked  with 
phlegmasia  dolens." 

The  latest  important  contribution  to  the  pathology  of  the  disease  is 
contained  in  two  papers  by  Dr.  Tilbury  Fox,  published  in  the  second 
volume  of  the  Obstetrical  Transactions,  He  maintained  that  some- 
thing beyond  the  mere  presence  of  coagula  in  the  veins  is  required  to 
produce  the  phenomena  of  the  disease,  although  he  admitted  that  to  be 
an  important  and  even  an  essential  part  of  the  pathological  changes 
present.  The  thrombi  he  believed  to  be  produced  either  by  extrinsic 
or  intrinsic  causes :  the  former  comprising  all  cases  of  pressure  by 
tumor  or  the  like ;  the  latter,  and  the  most  important,  being  divisible 
into  the  heads  of — 

1.  True  inflammatory  changes  in  the  vessels,  as  seen  in  the  epidemic 
form  of  the  disease. 
•    2.  Simple  thrombus  produced  by  rapid  absorption  of  morbid  fluid. 

3.  Virus  action  and  thrombus  conjoined,  the  phlegmasia  dolens 
itself  being  the  result  of  simple  thrombus,  and  not  produced  by  dis- 
eased (inflamed)  coats  of  vessels ;  the  general  symptoms  the  result  of 
the  general  blood  state. 

He  further  pointed  out  that  the  peculiar  swelling  of  the  limbs  cannot 
be  explained  by  the  mere  presence  of  oedema,  from  which  it  is  essen- 
tially different ;  the  white  appearance  of  the  skin,  the  severe  neuralgic 
pain,  and  the  persistent  numbness  indicating  that  the  whole  of  the 
cutaneous  textures,  the  cutis  vera,  and  even  the  epithelial  layer,  are 
infiltrated  with  fibrinous  deposit.  He  concluded,  therefore,  that  the 
swelling  is  the  result  of  oedema  plus  something  else — that  something 
being  obstruction  of  the  lymphatics,  by  which  the  absorption  of 
effused  serum  is  prevented.  The  efficient  cause  which  produces  these 
changes  he  believes  to  be,  in  the  majority  of  cases,  a  septic  action 
originating  in  the  uterus,  producing  a  condition  similar  to  that  in 
which  phlegmasia  dolens  arises  in  the  non-puerperal  state. 

[Although  crural  phlebitis  is  a  rare  sequel  of  the  Gesarean  section, 
it  has  followed  it  and  the  Porro  operation,  both  in  this  city  and  New 
York,  in  two  cases  of  each,  three  of  which  were  seen  by  the  writer. 
It  is  most  likely  to  occur  in  annsmic  subjects  or  where  there  has  been 
a  secondary  destruction  of  tissue  from  injurious  pressure  in  a  long 
labor.  In  my  experience  it  is  most  likely  to  show  itself  about  the 
middle  of  the  third  week.  The  disease  may  occur  in  delicate  men  and 
in  unmarried  women. — ED.] 


PERIPHERAL    VENOUS    THROMBOSIS.  677 

There  is  no  doubt  much  force  in  Dr.  Fox's  arguments,  and  it  may, 
I  think,  be  conceded  that  obstruction  of  the  veins  per  se  is  not  sufficient 
to  produce  the  peculiar  appearance  of  the  limb.  It  is,  moreover,  cer- 
tain that  phlebitis  alone  is  also  an  insufficient  explanation  not  only  of 
the  symptoms  but'  even  of  the  presence  of  thrombi  so  extensive  as  those 
that  are  found.  The  view  which  traces  the  disease  solely  to  inflam- 
mation or  obstruction  of  lymphatics  is  purely  theoretical,  has  no  basis- 
of  facts  to  support  it,  and  finds  nowadays  no  supporters.  The  experi- 
ments of  Mackenzie  and  Lee,  as  well  as  the  vastly  increased  knowledge 
of  the  causes  of  thrombosis  which  the  researches  of  modern  pathologists 
have  given  us,  seem  to  point  strongly  to  the  view  already  stated,  that 
the  disease  can  only  be  explained  by  a  general  blood  dyscrasia  de- 
pending on  the  puerperal  state.  It  by  no  means  follows  that  we  are 
to  consider  Dr.  Fox's  speculations  as  incorrect.  It  is  far  from  im- 
probable that  the  lymphatic  vessels  are  implicated  in  the  production 
of  the  peculiar  swelling,  only  we  are  not  as  yet  in  a  position  to  prove 
it.  There  is  no  inherent  improbability  in  the  supposition  that  the 
same  morbid  state  of  the  blood  which  produces  thrombosis  in  the  veins 
may  also  give  rise  to  such  an  amount  of  irritation  in  the  lymphatics 
as  may  interfere  with  their  functions  and  even  obstruct  them  alto- 
gether. The  essential  and  all-important  point  in  the  pathology  of  the 
disease,  however,  seems  undoubtedly  to  be  thrombosis  in  the  veins ; 
and  the  probability  of  there  being  some  as  yet  undetermined  patho- 
logical changes  in  addition  to  this,  by  no  means  militates  against  the 
view  I  have  taken  of  the  intimate  connection  of  the  disease  with  other 
results  of  thrombosis  in  different  vessels. 

Changes  occurring  in  the  Thrombi. — The  changes  which  take 
place  in  the  thrombi  all  tend  to  their  ultimate  absorption.  These 
have  been  described  by  various  authors  as  leading  to  organization  or 
suppuration.  It  is  probable,  however,  that  the  appearances  which 
have  led  to  such  a  supposition  are  fallacious,  and  that  they  are  really 
due  to  retrograde  metamorphosis  of  the  fibrin,  generally  of  an  amy- 
laceous or  fatty  character. 

Detachment  of  Emboli. — The  peculiarities  of  a  clot  that  must 
favor  detachment  of  an  embolus  are' such  a  shape  as  admits  of  a  portion 
floating  freely  in  the  blood  current  by  the  force  of  which  it  is  detached 
and  carried  to  its  ultimate  destination.  When  the  accident  has  occurred 
it  is  often  possible  to  recognize  the  peripheral  thrombus  from  which 
the  einbolus  has  separated,  by  the  fact  of  its  terminal  extremity  pre- 
senting a  freshly  fractured  end,  instead  of  the  rounded  head  natural  to 
it.  Such  detachment  is  unlikely  to  occur,  even  when  favored  by  the 
shape  of  the  clot,  unless  sufficient  time  has  elapsed  after  its  formation 
to  admit  of  its  softening  and  becoming  brittle.  The  curious  fact  I 
have  before  mentioned,  of  true  puerperal  embolism  occurring  in  the 
large  majority  of  cases  only  after  the  nineteenth  day  from  delivery, 
finds  a  ready  explanation  in  this  theory,  which  it  remarkably  cor- 
roborates. 

Treatment. — On  the  supposition  that  phlcgmasia  dolens  was  the 
result  of  inflammation  of  the  veins  of  the  affected  limb,  an  antiphlo- 
gistic course  of  treatment  was  naturally  adopted.  Accordingly,  most 


678  THE    PUERPERAL    STATE. 

writers  on  the  subject  recommended  depletion,  generally  by  the  appli- 
cation of  leeches  along  the  course  of  the  affected  vessels.  We  are  told 
that  if  the  pain  continues,  the  leeches  should  be  applied  a  second  or 
even  a  third  time.  If  we  admit  the  septic  origin  of  the  disease,  we 
must,  I  think,  see  the  impropriety  of  such  a  practice.  The  fact  that 
it  occurs  in  a  large  majority  of  cases  in  patients  of  a  weakly  and 
debilitated  constitution,  often  in  women  who  have  suffered  from  hemor- 
rhage, is  a  further  reason  for  not  adopting  this  routine  custom.  If 
local  loss  of  blood  be  used  at  all,  it  should  be  strictly  limited  to  cases 
in  which  there  is  much  tenderness  and  redness  across  the  course  of  the 
veins,  and  then  only  in  patients  of  plethoric  habits  and  strong  consti- 
tution. Cases  of  this  kind  will  form  a  very  small  minority  of  those 
coming  under  out  observation. 

What  has  been  said  of  the  pathology  of  the  affection  tends  to  the 
conclusion  that  active  treatment  of  any  kind,  in  the  hope  of  curing 
the  disease,  is  likely  to  be  useless.  Our  chief  reliance  must  be  on 
time  and  perfect  rest,  in  order  to  admit  of  the  thrombi  and  the 
secondary  effusion  being  absorbed,  while  we  relieve  the  pain  and  other 
prominent  symptoms  and  support  the  strength  and  improve  the 
constitution  of  the  patient. 

The  constant  application  of  heat  and  moisture  to  the  affected  limb 
will  do  much  to  lessen  the  tension  and  pain.  Wrapping  the  entire 
limb  in  linseed-meal  poultices,  frequently  changed,  is  one  of  the  best 
means  of  meeting  this  indication.  If,  as  is  sometimes  the  case,  the 
weight  of  the  poultice  be  too  great  to  be  readily  borne,  we  may  sub- 
stitute warm  flannel  stupes  covered  with  oiled  silk.  Local  anodyne 
applications  afford  much  relief,  and  may  be  advantageously  used  along 
with  the  poultices  and  stupes  either  by  sprinkling  their  surface  freely 
with  laudanum  or  chloroform  and  belladonna  liniment  or  by  soaking 
the  flannels  in  poppy-head  fomentations.  It  is  needless  to  say  that 
the  most  absolute  rest  in  bed  should  be  enjoined,  even  in  slight  cases, 
and  that  the  limb  should  be  effectually  guarded  from  undue  pressure, 
by  a  cradle  or  some  similar  contrivance.  Local  counter-irritation  has 
been  strongly  recommended,  and  frequent  blisters  have  been  considered 
by  some  to  be  almost  specific.  I  should  myself  hesitate  to  use  blisters, 
as  they  would  certainly  not  be  soothing  applications,  and  one  hardly 
sees  how  they  can  be  of  much  service  in  hastening  the  absorption  of 
the  effusion. 

During  the  acute  stage  of  the  disease  the  constitutional  treatment  must 
be  regulated  by  the  condition  of  the  patient.  Light  but  nutriotis  diet 
must  be  administered  in  abundance,  such  as  milk,  beef-tea,  and  soups. 
Should  there  be  much  debility,  stimulants  in  moderation  may  prove  of 
service.  With  regard  to  medicines,  we  shall  probably  find  benefit  from 
such  as  are  calculated  to  improve  the  condition  of  the  blood  and  the 
general  health  of  the  patient.  Chlorate  of  potash  with  diluted  hydro- 
chloric acid,  quinine  either  alone  or  in  combination  with  sesquicar- 
bonate  of  ammonia,  the  tincture  of  the  perchloride  of  iron,  are  the 
drugs  that  are  most  likely  to  prove  of  service.  Alkalies  and  other 
medicines,  which  have  been  recommended  in  the  hope  of  hastening  the 
absorption  of  coagula,  must  be  considered  as  altogether  useless.  Pain 


PERIPHERAL    VENOUS    THROMBOSIS.  679 

must  be  relieved  and  sleep  procured  by  the  judicious  use  of  anodynes, 
such  as  Dover's  powder,  the  subcutaneous  injection  of  morphia,  or 
chloral.  Generally  no  form  answers  so  well  as  the  hypodermic  in- 
jection of  morphia. 

When  the  acute  symptoms  have  abated  and  the  temperature  has 
fallen,  the  poultices  and  stupes  may  be  discontinued  and  the  limbs 
swathed  in  a  flannel  roller  from  the  toes  upward.  The  equable  pres- 
sure and  support  thus  afforded  materially  aid  the  absorption  of  the 
effusion  and  tend  to  diminish  the  size  of  the  limb.  At  a  still  later 
stage  very  gentle  inunctions  of  weak  iodine  ointment  may  be  used 
with  advantage  once  a  day  before  the  roller  is  applied.  Shampooing 
and  friction  of  the  limb,  generally  recommended  for  the  purpose  of 
hastening  absorption,  should  be  carefully  avoided,  on  account  of  the 
possible  risk  of  detaching  a  portion  of  the  coagulum  and  producing 
embolism.  This  is  no  merely  imaginary  danger,  as  the  following  fact 
narrated  by  Trousseau  proves :  "  A  phlegmasia  alba  dolens  had  ap- 
peared on  the  left  side  in  a  young  woman  suffering  from  peri-uterine 
phlegmon.  The  pain  having  ceased,  a  thickened  venous  trunk  was 
felt  on  the  upper  and  internal  part  of  the  thigh.  Rather  strong 
pressure  was  being  made,  when  M.  Demarquay  felt  something  yield 
under  his  fingers.  A  few  minutes  afterward  the  patient  was  attacked 
with  dreadful  palpitation,  tumultuous  cardiac  action,  and  extreme 
pallor,  and  death  was  believed  to  be  imminent.  After  some  hours, 
however,  the  oppression  ceased  and  the  patient  eventually  recovered. 
A  slightly  attached  coagulum  must  have  become  separated  and  con- 
veyed to  the  heart  or  pulmonary  artery." l  Warm  douches  of  water — 
of  salt  water,  if  it  can  be  obtained — may  be  advantageously  used  in 
the  later  stages  of  the  disease,  and  they  may  be  applied  night  and 
morning,  the  limb  being  bandaged  in  the  interval.  The  occasional 
use  of  the  continuous  current  is  said  to  promote  absorption,  and  would 
seem  likely  to  be  a  serviceable  remedy. 

When  the  patient  is  well  enough  to  be  moved,  a  change  of  air  to 
the  seaside  will  be  of  value.  Great  caution,  however,  should  be 
recommended  in  using  the  limb,  and  it  is  far  better  not  to  run  the 
risk  of  a  relapse  by  any  undue  haste  in  this  respect.  It  is  well  to  warn 
the  patient  and  her  friends  that  a  considerable  time  must  of  necessity 
elapse  before  the  local  signs  of  the  disease  have  completely  disappeared. 

i  Trousseau :  Clinique  de  l'H6tel-Dieu,  in  Qaa.  des  Hdp.,  1860,  p.  577. 


680  THE    PUEEPERAL    STATE. 


CHAPTER    X. 

PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS. 

Recognized  from  the  Earliest  Times. — From  the  earliest  times 
the  occurrence  after  parturition  of  severe  forms  of  inflammatory 
disease  in  and  about  the  pelvis,  frequently  ending  in  suppuration, 
has  been  well  known.  It  is  only  of  late  years,  however,  that  these 
diseases  have  been  made  the  subject  of  accurate  clinical  and  patho- 
logical investigation,  and  that  their  trae  nature  has  begun  to  be 
understood.  Nor  is  our  knowledge  of  them  as  yet  by  any  means 
complete.  They  merit  careful  study  on  the  part  of  the  accoucheur, 
for  they  give  rise  to  some  of  the  most  severe  and  protracted  illnesses 
from  which  puerperal  patients  suffer.  They  are  often  obscure  in  their 
origin  and  apt  to  be  overlooked,  and  they  not  rarely  leave  behind 
them  lasting  mischief. 

These  diseases  are  not  limited  to  the  puerperal  state.  On  the  con- 
trary, many  of  the  severest  cases  arise  from  causes  altogether  un- 
connected with  childbearing.  These  will  not  be  now  considered,  and 
this  chapter  deals  solely  with  such  forms  as  may  be  directly  traced  to 
childbirth. 

Modern  researches  have  demonstrated  that  there  are  two  distinct 
varieties  of  inflammatory  disease  met  with  after  labor  which  differ 
materially  from  each  other  in  many  respects.  In  one  of  these  the 
inflammation  affects  chiefly  the  connective  tissue  surrounding  the 
generative  organs  contained  within  the  pelvis,  or  extends  up  from 
beneath  the  peritoneum  and  into  the  iliac  fossse.  In  the  other  it 
attacks  that  portion  of  the  peritoneum  which  covers  the  pelvic  viscera, 
and  is  limited  to  it. 

Variety  of  Nomenclature. — So  much  is  admitted  by  all  writers ; 
but  great  obscurity  in  description,  and  consequent  difficulty  in  under- 
standing satisfactorily  the  nature  of  these  affections,  have  resulted 
from  the  variety  of  nomenclature  which  different  authors  have  adopted. 

Thus  the  former  disease  has  been  variously  described  as  pelvic  cellu- 
litis,  peri-uterine  phlegmon,  para-metritis,  or  pelvic  abscess ;  while  the 
latter  is  not  unfrequently  called  peri-metritis,  as  contradistinguished 
from  para-metritis.  The  use  of  the  prefix  para  or  peri,  to  distinguish 
the  cellular  or  peritoneal  variety  of  inflammation,  originally  suggested 
by  Virchow,  has  been  pretty  generally  adopted  in  Germany,  and  has 
been  strongly  advocated  in  Great  Britain  by  Matthews  Duncan.  It  has 
never,  however,  found  much  favor  with  English  writers,  and  the  simi- 
larity of  the  two  names  is  so  great  as  to  lead  to  confusion.  I  have, 
therefore,  selected  the  terms  pelvic  peritonitis  and  pelvic  cellulitis,  as  con- 
veying in  themselves  a  fairly  accurate  notion  of  the  tissues  mainly 
involved. 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.         681 

Importance  of  Distinguishing-  the  Two  Classes  of  Cases. — 
The  important  fact  to  remember  is  that  there  exist  two  distinct  varieties 
of  inflammatory  disease  presenting  many  similarities  in  their  course, 
symptoms,  and  results,  often  occurring  simultaneously,  but  in  the  main 
distinct  in  their  pathology  and  capable  of  being  differentiated.  Thomas 
compares  them — and,  as  serving  to  fix  the  facts  on  the  memory,  the 
illustration  is  a  good  one — to  pleurisy  and  pneumonia.  "  Like  them," 
he  says,  "  they  are  separate  and  distinct,  like  them  aifect  different  kinds 
of  structure,  and  like  them  they  generally  complicate  each  other."  It 
might,  therefore,  be  advisable,  as  most  writers  on  the  disease  occurring 
in  the  non-puerperal  state  have  done,  to  treat  of  them  in  two  separate 
chapters.  There  is,  however,  more  difficulty  in  distinguishing  them  as 
puerperal  than  as  non-puerperal  affections,  for  which  reason,  as  well  as 
for  the  sake  of  brevity,  I  think  it  better  to  consider  them  together, 
pointing  out  as  I  proceed  the  distinctive  peculiarities  of  each. 

Seat  of  Disease. — When  attention  was  first  directed  to  this  class  of 
diseases  the  pelvic  cellular  tissue  was  believed  to  be  the  only  structure 
affected.  This  was  the  view  maintained  by  Nonat,  Simpson,  and  many 
modern  writers.  Attention  was  first  prominently  directed  to  the  im- 
portance of  localized  inflammation  of  the  peritoneum,  and  to  the  fact 
that  many  of  the  supposed  cases  of  cellulitis  were  really  peritonitic, 
by  Bernutz.  There  can  be  no  doubt  that  he  here  made  an  enormous 
step  in  advance.  Like  many  authors,  however,  he  rode  his  hobby  a 
little  too  hard,  and  he  erred  in  denying  the  occurrence  of  cellulitis  in 
many  cases  in  which  it  undoubtedly  exists. 

Etiology. — The  great  influence  of  childbirth  in  producing  these  dis- 
eases has  long  been  fully  recognized.  Courty  estimates  that  about  two- 
thirds  of  all  the  cases  met  with  occur  in  connection  with  delivery  or 
abortion,  and  Duncan  found  that  out  of  40  carefully  selected  cases  25 
were  associated  with  the  puerperal  state. 

It  is  pretty  generally  admitted  by  most  modern  writers  that  both 
varieties  of  the  disease  are  produced  by  the  extension  of  inflammation 
from  either  the  uterus,  the  Fallopian  tubes,  or  the  ovaries.  This  point 
has  been  especially  insisted  on  by  Duncan,  who  maintains  that  the 
disease  is  never  idiopathic,  and  is  "invariably  secondary  either  to 
mechanical  injury,  or  to  the  extension  of  inflammation  of  some  of  the 
pelvic  viscera,  or  to  the  irritation  of  noxious  discharges  through  or 
from  the  tubes  or  ovaries." 

Their  intimate  connection  with  puerperal  septicaemia  is  also  a  prom- 
inent fact  in  the  natural  history  of  the  diseases.  Barker  mentions  a 
curious  observation  illustrative  of  this,  that  when  puerperal  fever  is 
endemic  in  the  Bellevue  Hospital,  in  New  York,  cases  of  pelvic  peri- 
tonitis and  cellulitis  are  also  invariably  met  with.  Olshausen  has  also 
remarked  that  in  the  Lying-in  Hospital  at  Halle,  during  the  autumn 
vacation,  when  the  patients  are  not  attended  by  practitioners,  and  when, 
therefore,  the  chance  of  septic  infection  being  conveyed  to  them  is  less, 
these  inflammations  are  almost  always  absent.  As  inflammation  of  the 
lining  membrane  of  the  uterus,  of  the  vaginal  mucous  membrane,  and 
of  the  pelvic  connective  tissue  are  of  very  constant  occurrence  as  local 
phenomena  of  septic  absorption,  the  connection  between  the  two  classes 


682  THE    PUERPERAL    STATE. 

of  cases  is  readily  susceptible  of  explanation.  Schroeder,  indeed,  goes 
further,  and  includes  his  description  of  these  diseases  under  the  head 
of  puerperal  fever.  They  do  not,  however,  necessarily  depend  upon 
it ;  for,  although  it  must  be  admitted  that  cases  of  this  kind  form  a 
large  proportion  of  those  met  with,  others  unquestionably  occur  which 
cannot  be  traced  to  such  sources,  but  are  the  direct  result  of  causes 
altogether  unconnected  with  the  inflammation  attending  on  septic 
absorption,  such  as  undue  exertion  shortly  after  delivery,  or  premature 
coition.  Mechanical  causes  may  beyond  doubt  excite  the  disease  in  a 
woman  predisposed  by  the  puerperal  process,  but  they  cannot  fairly  be 
included  under  the  head  of  puerperal  fever. 

Seat  of  the  Inflammation  in  Pelvic  Cellulitis. — Abundance  of 
areolar  tissue  exists  in  connection  with  the  pelvic  viscera,  which  may 
be  the  seat  of  cellulitis.  It  forms  a  loose  padding  between  the  organs 
contained  in  the  pelvis  proper,  surrounds  the  vagina,  the  rectum,  and 
the  bladder,  and  is  found  in  considerable  quantity  between  the  folds  of 
the  broad  ligaments.  From  these  parts  it  extends  upward  to  the  iliac 
fossae  and  the  inner  surface  of  the  abdominal  parietes.  In  any  of  these 
positions  it  may  be  the  seat  of  the  kind  of  inflammation  we  are  dis- 
cussing. The  essential  character  of  the  inflammation  is  similar  to  that 
which  accompanies  areolar  inflammation  in  other  parts  of  the  body. 
There  is  first  an  acute  inflammatory  cedema,  followed  by  the  infiltra- 
tion of  the  areolse  of  the  connective  tissue  with  exudation,  and  the  con- 
sequent formation  of  appreciable  swellings.  These  may  form  in  any 
part  of  the  pelvis.  Thus  we  may  meet  with  them — and  this  is  a  very 
common  situation — between  the  folds  of  the  broad  ligaments,  forming 
distinct  hard  tumors,  connected  with  the  uterus  and  extending  to  the 
pelvic  walls,  their  rounded  outlines  being  readily  made  out  by  bi- 
manual  examination.  If  the  cellulitis  be  limited  in  extent,  such  a 
swelling  may  exist  on  one  side  of  the  uterus  only,  forming  a  rounded 
mass  of  varying  size  and  apparently  attached  to  it.  At  other  times 
the  exudation  is  more  extensive,  and  may  completely  or  partially  sur- 
round the  uterus,  extending  to  the  cellular  tissue  between  the  vagina 
and  rectum  or  between  the  uterus  and  the  bladder.  In  such  cases  the 
uterus  is  imbedded  and  firmly  fixed  in  dense,  hard  exudation.  At  other 
times  the  inflammation  chiefly  affects  the  cellular  tissue  covering  the 
muscles  lining  the  iliac  fossae.  There  it  forms  a  mass  easily  made  out 
by  palpation,  but  on  vaginal  examination  little  or  no  trace  of  the 
exudation  can  be  felt,  or  only  a  sense  of  thickness  at  the  roof  of  the 
vagina  on  the  same  side  as  the  swelling. 

Seat  of  the  Inflammation  in  Pelvic  Peritonitis. — In  pelvic  peri- 
tonitis the  inflammation  is  limited  to  that  portion  of  the  peritoneum 
which  invests  the  pelvic  viscera.  Its  extent  necessarily  varies  with 
the  intensity  and  duration  of  the  attack.  In  some  cases  there  may  be 
little  more  than  irritation,  while  more  often  it  runs  on  to  exudation  of 
plastic  material.  The  result  is  generally  complete  fixation  of  the 
uterus  and  hardening  and  swelling  in  the  roof  of  the  vagina,  and  the 
lymph  poured  out  may  mat  together  the  surrounding  viscera,  so  as  to 
form  swellings,  difficult,  in  some  cases,  to  differentiate  from  those  re- 
sulting from  cellulitis.  On  post-mortem  examination  the  pelvic  viscera 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.    •     683 

are  found  extensively  adherent,  and  the  agglutination  may  involve  the 
coils  of  the  intestine  in  the  vicinity,  so  as  sometimes  to  form  tumors  of 
considerable  size. 

Relative  Frequency  of  the  Two  Forms  of  Disease. — The  relative 
frequency  of  these  two  forms  of  inflammation  as  puerperal  affections 
is  not  easy  to  ascertain.  In  the  non-puerperal  state  the  peritonitic 
variety  is  much  the  more  common,  but  in  the  puerperal  state  they  very 
generally  complicate  each  other,  and  it  is  rare  for  cellulitis  to  exist  to 
any  great  extent  without  more  or  less  peritonitis. 

Symptomatology. — The  earliest  symptom  is  pain  in  the  lower  part 
of  the  abdomen,  which  is  generally  preceded  by  rigor  or  chilliness. 
The  amount  of  pain  varies  much.  Sometimes  it  is  comparatively 
slight,  and  it  is  by  no  means  rare  to  meet  with  patients  who  are  the 
subjects  of  very  considerable  exudations  who  suffer  little  more  than  a 
certain  sense  of  weight  and  discomfort  at  the  lower  part  of  the  abdo- 
men. On  the  other  hand,  the  suffering  may  be  excessive,  and  is  char- 
acterized by  paroxysmal  exacerbations,  the  patient  being  comparatively 
free  from  pain  for  several  successive  hours,  and  then  having  attacks  of 
the  most  acute  agony.  Schroeder  says  that  pain  is  always  a  symptom 
of  peritonitis,  and  that  it  does  not  exist  in  uncomplicated  cellulitis. 
The  swellings  of  cellulitis  are  certainly  sometimes  remarkably  free 
from  tenderness,  and  I  have  often  seen  masses  of  exudation  in  the  iliac 
fossae  which  could  bear  even  rough  handling.  On  the  other  hand, 
although  this  is  certainly  more  often  met  with  in  non-puerperal  cases, 
the  tenderness  over  the  abdomen  is  sometimes  excessive,  the  patient 
shrinking  from  the  slightest  touch.  The  pulse  is  raised,  generally  from 
100  to  120,  and  the  thermometer  shows  the  presence  of  pyrexia.  Dur- 
ing the  entire  course  of  the  disease  both  these  symptoms  continue.  The 
temperature  is  often  very  high,  but  more  frequently  it  varies  from  100° 
to  104°,  and  it  generally  shows  more  or  less  marked  remissions.  In 
some  cases  the  temperature  is  said  not  to  be  elevated  at  all,  or  even  to 
be  subnormal,  but  this  is  certainly  quite  exceptional.  Other  signs  of 
local  and  general  irritation  often  exist.  Among  them,  and  most  dis- 
tinctly in  cases  of  peritonitis,  are  nausea  and  vomiting,  and  an  anxious, 
pinched  expression  of  the  countenance,  while  the  local  mischief  often 
causes  distressing  dysuria  and  tenesmus.  The  latter  is  especially  apt 
to  occur  when  there  is  exudation  between  the  rectum  and  vagina  which 
presses  on  the  bowel.  The  passage  of  feces,  unless  in  a  very  liquid 
form,  may  then  cause  intolerable  suffering. 

Such  symptoms  may  show  themselves  within  a  few  days  after 
delivery,  and  then  they  can  barely  fail  to  attract  attention.  On  the 
other  hand,  they  may  not  commence  for  some  weeks  after  labor,  and 
then  they  are  often  insidious  in  their  onset  and  apt  to  be  over- 
looked. It  is  far  from  rare  to  meet  with  cases  six  weeks  or  more  after 
confinement  in  which  the  patient  complains  of  little  beyond  a  feeling 
of  malaise  and  discomfort,  and  in  which,  on  investigation,  a  consider- 
able amount  of  exudation  is  detected  which  had  previously  entirely 
escaped  observation. 

Results  of  Physical  Examination.— On  introducing  the  finger 
into  the  vagina  it  will  be  found  to  be  hot  and  swollen,  in  some  cases 


THE    PUERPERAL    STATE. 

distinctly  oedematous,  and  on  reaching  the  vaginal  cul-de-sac  the  exist- 
ence of  exudation  may  generally  be  made  out.  The  amount  of  this 
varies  much.  Sometimes,  especially  in  the  early  stage  of  the  disease, 
there  is  little  more  than  a  diffuse  sense  of  thickness  and  induration  at 
either  side  of,  or  behind,  the  uterus.  More  generally,  careful  binianual 
examination  enables  us  to  detect  a  distinct  hardening  and  swelling, 
possibly  a  tumor  of  considerable  size,  which  may  apparently  be  attached 
to  the  sides  of  the  uterus  and  rise  above  the  pelvic  brim,  or  may  extend 
quite  to  the  pelvic  walls.  The  examination  should  be  very  carefully 
and  systematically  conducted  with  both  hands,  so  as  to  explore  the 
whole  contour  of  the  uterus  before,  behind,  and  on  either  side,  as  well 
as  the  iliac  fossse ;  otherwise  a  considerable  exudation  might  readily 
escape  detection. 

When  the  exudation  is  at  all  great,  more  or  less  fixity  of  the 
uterus  is  sure  to  exist,  and  this  is  a  very  characteristic  symptom. 
The  womb,  instead  of  being  freely  movable  by  the  examining  finger, 
is  firmly  fixed  by  the  surrounding  exudation,  and  in  severe  forms 
of  the  disease  is  quite  incased  in  it.  More  or  less  displacement 
of  the  organ  is  also  of  common  occurrence.  If  the  swelling  be  limited 
to  one  side  of  the  pelvis  or  to  Douglas's  space,  the  uterus  is  displaced 
in  the  opposite  direction,  so  that  it  is  no  longer  in  its  usual  central 
position. 

The  differential  diagnosis  of  pelvic  cellulitis  and  pelvic  peritonitis 
cannot  always  be  made,  and  indeed  in  many  cases  it  is  impossible, 
since  both  varieties  of  disease  coexist.  The  elements  of  differentiation 
generally  insisted  on  are,  the  greater  general  disturbance,  nausea,  etc., 
in  pelvic  peritonitis,  with  an  earlier  commencement  of  the  symptoms 
after  labor.  The  swellings  of  pelvic  peritonitis  are  also  more  tender, 
with  less  clearly  defined  outline  than  those  of  cellulitis.  When  the 
cellulitis  involves  the  iliac  fossa  the  diagnosis  is,  of  course,  easy,  and 
then  a  continuous  retraction  of  the  thigh  on  the  affected  side  (an  in- 
voluntary position  assumed  with  the  view  of  keeping  the  muscles 
lining  the  iliac  fossa  at  rest)  is  often  observed.  When  the  inflam- 
mation is  chiefly  limited  to  the  cavity  of  the  pelvis,  the  distinction 
between  the  two  classes  of  cases  cannot  be  made  with  any  degree  of 
certainty. 

Terminations. — Both  forms  of  disease  may  end  either  in  resolution 
or  in  suppuration.  In  the  former  case,  after  the  acute  symptoms  have 
existed  for  a  variable  time,  it  may  be  for  a  few  days  only,  it  may  be 
for  many  weeks,  their  severity  abates,  the  swellings  become  less  tender 
and  commence  to  contract,  become  harder,  and  are  gradually  absorbed, 
until  at  last  the  fixity  of  the  uterus  disappears  and  it  again  resumes 
its  central  position  in  the  pelvic  cavity.  This  process  is  often  very 
gradual.  It  is  by  no  means  rare  to  find  a  patient,  even  some  months 
after  the  attack,  when  all  acute  symptoms  have  long  disappeared,  who 
is  even  able  to  move  about  without  inconvenience,  in  whom  the  uterus 
is  still  immovably  fixed  in  a  mass  of  deposit,  or  is  at  least  adherent 
in  some  part  of  its  contour.  More  or  less  permanent  adhesions  are 
of  common  occurrence,  and  give  rise  to  symptoms  of  considerable 
obscurity,  which  are  often  not  traced  to  their  proper  source. 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.         685 

Symptoms  of  Suppuration. — When  the  inflammation  is  about  to 
terminate  in  suppuration,  the  pyrexial  symptoms  continue,  and  event- 
ually well-marked  hectic  is  developed,  the  temperature  generally  show- 
ing a  distinct  exacerbation  at  night.  At  the  same  time  rigors,  loss  of 
appetite,  a  peculiar  yellowish  discoloration  of  the  face,  and  other  signs 
of  suppuration,  show  themselves.  The  relative  frequency  of  this  ter- 
mination is  variously  estimated  by  authors.  Duncan  quoted  Simpson 
as  calculating  it  to  occur  in  half  the  cases  of  pelvic  cellulitis,  but 
stated  his  own  belief  that  it  is  much  more  frequent.  West  observed  it 
in  23  out  of  43  cases  following  delivery  or  abortion,  and  McClintock 
in  37  out  of  70.  Schroeder  said  that  he  had  only  once  seen  suppura- 
tion in  92  cases  of  distinctly  demonstrable  exudation,  a  result  which  is 
certainly  totally  opposed  to  common  experience.  Barker  also  stated 
that  in  his  experience  suppuration  in  either  pelvic  peritonitic  or  cellu- 
litis "is  very  rare,  except  when  they  are  associated  with  pyaemia  or 
puerperal  fever."  It  is  certain  that  suppuration  is  more  likely  to 
occur  in  pelvic  cellulitis  than  in  pelvic  peritonitis,  but  it  unquestion- 
ably occurs,  in  Great  Britain  at  least,  much  more  frequently  than  the 
statements  of  either  of  these  authors  would  lead  us  to  suppose. 

Channels  through  which  Pus  may  Escape. — The  pus  may  find 
an  exit  through  various  channels.  In  pelvic  cellulitis,  more  especially 
when  the  areolar  tissue  of  the  iliac  fossa  is  implicated,  the  most  com- 
mon site  of  exit  is  through  the  abdominal  wall.  It  may,  however, 
open  at  other  positions,  and  the  pus  may  find  its  way  through  the 
cellular  tissue  and  point  at  the  side  of  the  anus  or  in  the  vagina,  or  it- 
may  take  even  a  more  tortuous  course  and  reach  the  inner  surface  of 
the  thigh.  Pelvic  abscesses  not  uncommonly  open  into  the  rectum  or 
bladder,  causing  very  considerable  distress  from  tenesmus  or  dysuria. 
According  to  Hervieux,  it  is  chiefly  the  peritoneal  varieties  which  open 
in  this  way.  Not  un frequently  more  than  one  opening  is  formed;  and 
when  the  pus  has  burrowed  for  any  distance  long  fistulous  tracts  result 
which  secrete  pus  for  a  length  of  time  and  are  very  slow  to  heal. 
Rupture  of  an  abscess  into  the  peritoneal  cavity,  especially  of  a  peri- 
tonitic abscess,  is  a  possible  (but  fortunately  a  very  rare)  termination, 
and  will  generally  prove  fatal  by  producing  general  peritonitis.  In 
one  case  which  I  have  recorded  in  the  fifteenth  volume  of  the  Obstet- 
rical Transactions,  suppuration  was  followed  by  extensive  necrosis  of 
the  pelvic  bones.  Two  similar  cases  are  related  by  Trousseau  in  his 
Clinical  Medicine,  but  I  have  not  been  able  to  meet  with  any  other 
examples  of  this  rare  complication,  which  was  probably  rather  the 
result  of  some  obscure  septicaemic  condition  than  of  extension  of  the 
inflammation. 

Prognosis. — The  prognosis  is  favorable  as  regards  ultimate  recovery, 
but  there  is  great  risk  of  a  protracted  illness  \yhich  may  seriously  im- 
pair the  health  of  the  patient,  especially  if  suppuration  result.  Hence 
it  is  necessary  to  be  guarded  in  an  expression  of  opinion  as  to  the  con- 
sequences of  the  disease.  Secondary  mischief  is  also  far  from  unlikely 
to  follow,  from  the  physical  changes  produced  by  the  exudation,  such 
as  permanent  adhesions  or  malpositions  of  the  uterus,  or  organic  alter- 
ations in  the  ovaries  or  Fallopian  tubes. 


686  THE    PUERPERAL    STATE. 

Treatment. — In  the  treatment  of  both  forms  of  disease  the  impor- 
tant points  to  bear  in  mind  are  the  relief  of  pain  and  the  necessity  of 
absolute  rest;  and  to  these  objects  all  our  measures  must  be  subordinate, 
since  it  is  quite  hopeless  to  attempt  to  cut  short  the  inflammation  by 
any  active  medication. 

If  the  disease  be  recognized  at  a  very  early  stage,  the  local  abstrac- 
tion of  blood  by  the  application  of  a  few  leeches  to  the  groin  or  to  the 
hemorrhoidal  veins  may  give  relief;  but  the  influence  of  this  remedy 
has  been  greatly  exaggerated,  and  when  the  disease  is  of  any  standiug 
it  is  quite  useless.  Leeches  to  the  uterus,  often  recommended,  are,  I 
believe,  likely  to  do  more  harm  than  good  (unless  in  very  skilful 
hands),  from  the  irritation  produced  by  passing  the  speculum.  Opiates 
in  large  doses  may  be  said  to  be  our  sheet-anchor  in  treatment  when- 
ever the  pain  is  at  all  severe,  either  by  the  mouth,  in  the  form  of 
morphia  suppositories,  or  injected  subcutaneously.  In  the  not  un- 
common cases  in  which  pain  conies  on  severely  in  paroxysms,  the 
opiates  should  be  administered  in  sufficient  quantity  to  lull  the  pain ; 
and  it  is  a  good  plan  to  give  the  nurse  a  supply  of  morphia  supposi- 
tories (which  often  act  better  than  any  other  form  of  administering  the 
drug),  with  directions  to  use  them  immediately  the  pain  threatens  to 
come  on.  When  there  is  much  pyrexia  large  doses  of  quinine  may  be 
given  with  great  advantage  along  with  the  opiates.  The  state  of  the 
bowels  requires  careful  attention.  The  opiates  are  apt  to  produce  con- 
stipation, and  the  passage  of  hardened  feces  causes  much  suffering. 
Hence  it  is  desirable  to  keep  the  bowels  freely  open.  Nothing  answers 
this  purpose  so  well  as  small  doses  of  castor  oil,  such  as  half  a  tea- 
spoonful  given  every  morning.  Warmth  and  moisture  constantly 
applied  to  the  lower  part  of  the  abdomen  give  great  relief,  either  in 
the  form  of  large  poultices  of  linseed-meal,  or,  if  these  prove  too  heavy, 
of  spougio-piline  soaked  in  boiling  water.  The  poultices  may  be 
advantageously  sprinkled  with  laudanum  or  belladonna  liniment.  I 
say  nothing  of  tlie  use  of  mercurials,  iodide  of  potassium,  and  other 
so-called  absorbent  remedies,  since  I  believe  them  to  be  quite  valueless 
and  apt  to  divert  attention  from  more  useful  plans  of  treatment. 

The  most  absolute  rest  in  the  recumbent  position  is  essential,  and  it 
should  be  persevered  in  for  some  time  after  the  intensity  of  the 
symptoms  is  lessened.  The  beneficial  effect  of  rest  in  alleviating  pain 
is  often  seen  in  neglected  cases,  the  nature  of  which  has  been  over- 
looked, instant  relief  following  the  laying  up  of  the  patient. 

When  the  acute  symptoms  have  lessened,  absorption  of  the  exuda- 
tion may  be  favored  and  considerable  relief  obtained  from  counter- 
irritation,  which  should  be  gentle  and  long-continued.  The  daily  use 
of  tincture  of  iodine  until  the  skin  peels,  perhaps  best  meets  this  indi- 
cation, but  frequently  repeated  blisters  are  often  very  serviceable. 
This  I  believe  to  be  a  better  plan  than  keeping  up  an  open  sore  with 
savine  ointment  or  similar  irritating  applications. 

When  suppuration  is  established,  the  question  of  opening  the  abscess 
arises.  When  this  points  in  the  groin  and  the  matter  is  superficial,  a 
free  incision  may  be  made,  and  here,  as  in  mammary  abscess,  the  anti- 
septic treatment  is  likely  to  prove  very  serviceable.  The  abscess 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.         687 

should,  however,  not  be  opened  too  soon,  and  it  is  better  to  wait  until 
the  pus  is  near  the  surface.  The  importance  of  not  being  in  too  great 
a  hurry  to  open  pelvic  abscesses  has  been  insisted  on  by  West,  Duncan, 
and  other  writers,  and  I  have  no  doubt  the  rule  is  a  good  one.  It  is 
more  especially  applicable  when  the  abscess  is  pointing  in  the  vagina 
or  rectum,  where  exploratory  incisions  are  apt  to  be  dangerous,  and 
when  the  presence  of  pus  should  be  positively  ascertained  before 
operating.  We  have  in  the  aspirator  a  most  useful  instrument  in  the 
treatment  of  such  cases,  which  enables  us  to  remove  the  greater  part 
of  the  pus  without  any  risk,  and  the  use  of  which  is  not  attended 
with  danger,  even  if  employed  prematurely.  If  it  does  not  sufficiently 
evacuate  the  abscess,  a  free  opening  can  afterward  be  safely  made  and 
a  suitable  drainage-tube  inserted  into  the  abscess  cavity.  The  surgical 
treatment  of  pelvic  abscess  is,  however,  too  wide  a  subject  to  admit  of 
being  satisfactorily  treated  here. 

The  diet  should  be  abundant,  but  simple  and  nutritious.  In  the 
early  stages  of  the  disease,  milk,  beef-tea,  eggs,  and  the  like  will  be 
sufficient.  After  suppuration  a  large  quantity  of  animal  food  is  neces- 
sary, and  a  sufficient  amount  of  stimulants.  The  drain  on  the  system 
is  then  often  very  great,  and  the  amount  of  nourishment  patients  will 
require  and  assimilate,  when  a  copious  purulent  discharge  is  going  on, 
is  often  quite  remarkable.  A  general  tonic  plan  of  medication  .is 
also  indicated,  and  such  drugs  as  iron,  quinine,  and  cod-liver  oil  will 
prove  useful. 


INDEX. 


A  BDOMINAL  ges 
A     pregnancy,  191 


tation,  179,  181 


Abortion  and  premature  labor,  252 

causes  of,  254 

definition  of,  253 

importance  and  frequency  ofr  252 

most  common  in  multipart,  253 

of  artificial,  207 

production  of,  417 

symptoms  of,  258 

subsequent  management  of,  264 

treatment  of,  259 

tubal,  183 

Abscess,  mammary,  596 
After-pains,  277,  582 

treatment  of  severe,  583 

-coming  head,  perforation  of,  528 
Ala  vespertilionis,  70 
Albumin  in  urine  of  pregnant  women,  212 

predisposes  to  abortion,  214 
Albuminuria,  prognosis  of,  214 

of  pregnancy,  induction  of  premature 
labor  in,  216 

symptoms  of,  215 

treatment  of,  215 
Allantois,  110 
Amnion,  112 

diagnosis  of,  246 

formation  of,  108 

pathology  of,  245 

treatment  of,  246 

Anaemia  and  chlorosis  in  affections  of  re- 
spiratory organs,  211 
Anaesthesia  in  labor,  308 
Anaesthetics,    question    of   administering, 

502,  546 

Anatomy  and  physiology  of  fretus,  122 
Ante-partum  hour-glass  contraction,  371 
Anteversion,  223 
Antipyrine  in  pregnancy,  206 
Area  germinativa,  107 

pellucida,  107 
Arm,  dorsal  displacement  of,  345 

presentation,  cases  of,  492 
Arterial  thrombosis  and  embolism,  668 
causes  of,  668 
symptoms  of,  669 
treatment  of,  670 
Articulations,  pelvic,  36 
Artificial  dilatation,  368 
Auscultatory  signs  of  pregnancy,  158 


T)ALLOTTEMENT  in  pregnancy,  157 
O     Belladonna  in  pregnancy,  206 
[Binder,  time  to  apply,  302,  303,  306] 
Births,  frequency  of  multiple,  173 
plural,  379 
treatment  of,  380 
Bladder,  irritability  of,  220 
Blood,  defibrination  of,  568,  572 
injection  of,  573 

in  pregnancy,  composition  of,  145 
[transfusion  of,  564,  574] 

Aveling's  method  of,  566 
history  of,  564 
nature  and  object  of,  565 
Roussel's  method  of,  567 
Schafer's  method  of,  567,  571 
Body,  extraction  of,  534 
Bowels,  action  of,  585 
[Breech  forceps,  322] 

[position,  important  to  change  to  ver- 
tex, 314] 

Brim,  contracted,  406 
Broad  ligaments  of  uterus,  69 
Brow  presentations,  332 


nADUCA,  102 

\J     [Caesarean  section,  in  the  U.  S.,  370] 
[danger  of,  in  the  U.  S  ,  417] 
[elective,  541] 
[for  transverse  positions  in 

the  U.  S.,  344,  345] 
[history  of,  537,  552] 
[horn-rips,  537,  538] 
[in  cancer  of  cervix  in  the 

U.  S.,  370] 
[in  Europe,  539] 
[in  pelvic  exostosis,  in  the 

U.  S.,  405] 
[in  1893,  551,  552] 
Calculus,  vesical,  375 
Caput  succedaneum,  formation  of,  289 
Carcinoma,  231 

Cardiac  murmurs  in  pulmonary  obstruc- 
tion, 664 

Carunculae  myrtiformes,  53 
Cellulitis,  pelvic,  680 
Cephalalgia  as  a  cause  of  albumin  in  urine, 

214 

Cephalic  version,  479 
Cephalotribe,  524 
44  (689) 


690 


INDEX. 


Cephalotripsy  and   craniotomy,  compara- 
tive merits  of,  530 
Cervix,  cavity  of,  59 

changes  in,  during  pregnancy,  142 

mucous  membrane  of,  64 

rigidity  of,  366 

softening  of,  157 
Chapman's  spinal  ice-bag,  206 
Child,  clothing  of,  589  • 

examination  of,  323 

expulsion  of,  267,  301 

management  of  suckling  of,  591 

over-frequent  suckling  of,  589 

position  of,  at  brim,  315 

risk  to,  405 

washing  and  dressing  of,  588 
Childbirth,  management  of  women  after, 
582 

mortality  of,  575 
Chloral  in  pregnancy,  206 
[Chloroform  inhalation,  objected  to  in  the 

U.S.,  311] 
Chorea  in  first  pregnancy,  218 

prognosis  of,  219 

treatment  of,  219 
Chorion,  disease  of,  237 
causes  of,  237 
pathology  of,  237,  238 
progress  of,  239 
symptoms  of,  239 
treatment  of,  240 

hydatidiform  degeneration  of,  237 
Circulation  of  foetus,  134 
[Clay-eating,  producing  pelvic  obstruction 

in  Southern  U.  S.,  376] 
Cleanliness,  attention  to,  584 
Clitoris,  51 

Coagulation  in  puerperal  state,  658 
Cocaine  in  pregnancy,  206 
Coccyx,  anatomy  of,  36 

ligaments  of,  37 
Ccelio-elytrotomy,  553 

cases  suitable  for,  554 
history  of,  553 
nature  of  operation  of,  554 
operation  of,  553 
Cceliotomy,  655 

mode  of  performing  secondary,  197 
[Color-line  of  abdomen  in  pregnancy,  155] 
Conception  and  generation,  96 

fruitful,  signs  of,  150 

mental  peculiarities  in,  152 

morning  sickness  a  sign  of,  151 
Constipation  in  pregnancy,  208 
Continued  fevers,  228 
Cough,  spasmodic,  210 
Cow's  milk  and  its  preparation,  600 
[Coxalgia,  causing  pelvic  deformity,  402] 
Cranioclast,  524 
Craniotomy,  cases  requiring,  526 

religious  objections  to,  522 

when  justifiable,  528 
Cross-births,  337 
Crural  phlebitis,  675 
Culbute,  128 


Curetting  the  uterine  cavity,  651 

Curve,  pelvic,  496 

Cyst,  formation  of,  around  ovum,  191 

opening,  by  caustics,  197 
Cystic  disease  of  ovum,  237 
Cystocele,  vaginal,  375 


DECAPITATION,  522,  535 
U     Decidua,  102 

pathology  of,  234 
Deformities  of  pelvis,  391,  394 
causes  of,  392 
classification  of,  391 

Delivery,  alterations  in  blood  after,  576 
[instance  of  rapid  natural,  365] 
instrumental,  3(51 
probable  date  of,  168 
signs  of  recent,  171 
Diabetes  in  pregnancy,  216 
Diarrhoea  in  pregnancy,  208 
Diet  and  regimen,  583 
Digestive  system,  derangements  of,  204 
disorders  of,  in  pregnancy,  208 
Dilatation,  273 

artificial,  368 
Discus  proligerus,  80 
Dizziness  as  a  cause  of  albumin  in  urine, 

214 

Dorsal  displacement  of  arm,  345 
Double  monsters,  38'J 

division  of,  384 

Douches,  vaginal  and  uterine,  475 
Dropsical  effusions,  389 
Dyspnoea  in   early  months  of  pregnancy, 

210 
Dystocia  in  labor,  390 

treatment  of,  391 


rr?CLAMPSIA,  612] 

|_Ij     Ecraseur,  526 

Emboli,  detachment  of,  677 

Embryotomy,  323,  535 

Endochorion,  114 

Endometritis  decidualis  polyposa,  235 

tuberosa,  235 
Epilepsy,  229 
Eruptive  fevers,  227 
Erysipelas,  infection  from,  631 
Evisceration,  522,  535,  536 
Evolution,  spontaneous,  342 
Exochorion,  114 
Expressio  foetus,  359 
Extra-uterine  pregnancy,  179 

condition  of  uterus  in,  184 

etiology  of,  181 
Eye,  diseases  of,  230 


T7ACE  presentations,  323 
1?  descent  in,  327 

extension  in,  327 

flexion  in,  328 

four  positions  met  with  in,  326 


INDEX. 


691 


Face  presentations — 

frequency  of,  324 
mechanism  of,  325 
prognosis  of,  330 
rotation  in,  327 

external,  328 
treatment  of,  330 
-to-pubes  delivery,  causes  of,  333 

treatment  of,  334 
Fallopian  tubes,  72 
Faradic  current,  use  of,  359 
Fatty   transformation  of  muscular  fibres, 

579 

Female  generative  organs,  49 
Fevers,  continued,  228 

eruptive,  227 
Fibroid  tumors,  233 
Figure-of-eight  deformity,  397 
Fillet,  521 

Foetal  head,  anatomy  of,  125 
heart-sounds,  159 
membranes  and  placenta,  arrangement 

of,  175 

movements  in  pregnancy,  155 
skull,  diameters  of,  126 
tumors  obstructing  delivery,  390 
[Foatus,  alvvavs  small,  with  some  women, 

124]     ' 

anatomy  and  physiology  of,  122 
appearances   of,  at  various  stages  of 

growth,  122 
at  term,  124 
circulation  of,  134 
death  of,  192,  251   ' 
diagnosis  of,  252 
symptoms  of,  252 
destruction  of,  521 

operations  involving,  521 
functions  of,  131 
means  of  destroying,  189 
pathology  of,  247 
position  of,  337 

found  by  palpation,  129 
respiration  of,  133 
wounds  and  injuries  of,  249 
Foetuses,  size  of,  in  multiple  pregnancies, 

174 
Food   and   stimulants,   administration   of, 

652 

Foot,  bringing  down,  322 
Forceps,  322,  412,  494 
action  of,  500 

antiseptic  precautions  in  use  of,  503 
application  of,  within  cervix,  370 

to  after-coming  head,  321 
Continental,  498 
[craniotomy,  Meigs's,  534,  535] 
crochets  and  craniotomy,  523 
description  of,  494 
dynamical  action  of,  501 
extraction  by  craniotomy,  533 
Hodge,  511 
[in  America,  509,  519] 
long,  497 
method  of  applying,  502 


Forceps — 

mode  of  introducing  lower  blade,  504 
upper  blade,  505 
blades  in  high  forceps  opera- 
tions, 508 

possible  dangers  of  delivery  by,  508 
Sawyer,  513 
section  of  skull  by,  526 
short,  495 

Simpson's  axis-traction,  499 
Tarnier's,  499 
use  of,  in  modern  practice,  494 

possible  dangers  attending,  362 
Zeigler's,  496 
Fossa  navicularis,  53 
Fractures,  deformity  from,  404 
Funic  souffle,  161 


pro- 


r\  ALACTOPHOKOUS  ducts,  81 
vJ     General   modifications  in   body 

duced  by  pregnancy,  145 
Generative  organs  in  female,  49 
Gestation,  abdominal,  diagnosis  of,  193 

treatment  of,  194,  198,  200 
in  a  bi-lobed  uterus,  198 
Glands,  mammary,  80 
vulvo-vaginal,  53 
Graafian  follicles,  77,  79 
changes  in,  83 

Greenhalgh's  pelvimeter,  410 
Groin,  traction  on,  322 


TJ^EMATIC  effusions,  376 
11  symptoms  of,  377 

treatment  of,  377 
Hand-feeding,  599 

method  of,  602 

Harris's  symphyseotomy  bistoury,  561 
Head,  birth  of,  320 

delivery  of,  817 

position  of,  mode  of  recognizing,  279 

presentations,  delivery  in,  406 

four  positions  described,  279,  289 
mechanism  of  delivery  in,  278 

shape  of,  from  moulding,  290 
Hearson's  thermostatic  nurse,  478 
Heart  disease,  228 
Hemorrhage,  430 

[after  delivery,  treated  by  position  of 
woman,  445] 

after  rupture  of  vein,  222 

before  delivery,  418 

causes  of,  430 

constitutional  causes,  448 

curative  treatment  of,  439 

definition  of,  430,  433 

diagnosis  of,  431 

differential  diagnosis  of,  432 

from  laceration  of  maternal  structures, 
446 

importance  of,  433 

local  causes,  448 

pathology  of,  430 


692 


INDEX. 


Hemorrhage — 

post-partum,  433,  447 

preventive  treatment  of,  438 

prognosis  of,  432 

secondary,  447 

symptoms  of,  431 

treatment  of,  432,  449 
Hemorrhoids  in  pregnancy,  209 
Hernial  protrusion,  375 
Heterogenetic  infection,  source  of,  630 
Hip-joint  disease,  404 
Hour-glass  contractions,  436 

treatment  of,  441 
[Hydramnios,  245,  246] 
Hydrocephalus,  intra-uterine,  387 
Hydro  perione,  105 
Hydrorrhrea  gravidarum,  236 
[Hysterectomy,  supra-vaginal,  when  not  a 
Porro  operation,  458] 


TCE-BAGS  in  pregnancy,  206 
1     Idiopathic  asphyxia,  670 
Impregnation,  99 

sites  of,  98 

Incontinence  of  urine,  220 
Induction  of  premature  labor,  469 

history  of,  469 

operation  of,  469 

puncture   of  membranes  in, 
471 

various  methods  of,  471 
Infant,  management  of,  586 
Infantile  mortality,  effect  of  early  inter- 
ference on,  362 
Infection  from  erysipelas,  631 
Injection  of  saline  solutions,  569 
Insanity  of  lactation,  618 

puerperal,  612,  615 
Instrumental  delivery,  361 
Interstitial  and  false  ovarian  pregnancy, 

185 

Intestines,  scybalous  masses  in,  376 
Intra-uterine  hydrocephalus,  387 

diagnosis  of,  388 

treatment  of,  389 

Irregular  and  spasmodic  pains,  356 
Irritability  of  bladder,  220 
[Ischio-pubiotomy,  unilateral,  563] 


JAUNDICE,  simple,  230 
tl     Joint,  lumbo-sacral,  36 


LABIA  majora,  49 
minora,  50 

Labor,  abortion  and  premature,  252 
after-treatment  of,  307 
anaesthesia  in,  308 
antiseptic  precautions  in,  292 
attention  to  cleanliness  in,  C94 
causes  of,  265 
chloral  in,  308 
chloroform  in,  308,  309 


Labor — 

complicated  with  tumor,  372 

course  of,  406 

'delay  in  first  stage  of,  353 

division  of,  into  stages,  272 

duration  of,  277 

duties  on  first  visiting  patient  in,  292 

effects  of  prolongation  of,  367 

ether  in,  308,  310 

false  pains  in,  294 

first  summons  in,  291 

[induced    prematurely,   mortality  in, 
477] 

induction  of  premature,  469 

management  of  natural,  290 

management  of  third  stage  of,  302 

methylene  in,  308 

[missed,  198,  201-203] 

mode  of  conducting  vaginal  examina- 
tion in,  295 

objections  to  theories  of,  267 

obstructed  by  faulty  condition  of  soft 
parts,  366 

pains  during,  271 

phenomena  of,  265 

position  of  patient  during  first  stage 

of,  296 
second  stage  of,  297 

precipitate,  351 

preparatory  treatment  in  management 
of,  290 

prolonged,  351 

protraction  in  second  stage  of,  353 

stage  of,  first,  273 

premonitory,  273 
preparatory,  272 
second,  274 
third,  275 

treatment,  367 

true  pains  in,  294 

use  of  antiseptic  injections  in,  293 

vaginal  examinations  in,  294 
Laceration  of  veins,  222 
Lactation,  585 

disorders  of,  593 

insanity  of,  618 

signs  of  successful,  592 
Laminae  dorsales,  107 
Leeches  in  pregnancy,  206 
Leipothymia,  211 
Leucorrhcea,  220 
Ligaments  of  coccyx,  57 
Liquor  amnii,  deficiency  of,  246 
Lit  hopaed  ion,  193 
Liver,  changes  in,  148 

function  of,  136 
Lochial  discharge,  581 
Locked  twins,  difficulties  arising  from,  381 
Lumbo-sacral  joint,  36 


MALPRESENTATIOX,    frequency    of. 
Si    406 

Mammary  abscess,  596 

method  of  opening,  597 


INDEX. 


693 


Mammary  abscess — 

treatment  of,  597 

glands,  80 
Mania  during  delivery,  transient,  615  • 

puerperal,  612 
Maturation,  83 
Measles,  228 

Mechanism  of  delivery  in  head  presenta- 
tions, 278 

Membrane,  sub-zonal,  108,  114 
Membranes,  management  of,  306 

puncture  of,  425 

rupture  of,  488 

separation  of,  475 
Menstruation,  86 

cessation  of,  94 
period  of,  94 

cyclical  theory  of,  93 

duration  of  period  of,  89 
.  influence  of  climate  on,  87 
of  cold  on,  87 

law  in  reference  to,  93 

theory  of,  82,  91 
Menthol  in  pregnancy,  206 
Milk,  artificial  human,  600 

[as  a  diet  for  nursing  mothers,  594] 

cow's,  600 

excessive  flow  of,  595 

secretion  of,  means  of  arresting,  593 
defective,  593 

transfusion  of,  569 
Miscarriage,  253 
Missed  labor,  198 
Mole,  fleshy,  255 

vesicular  237 
Monsters,  double,  382,  384 
Mons  Veneris,  49 
Morphia  in  pregnancy,  206 
Mother,  diseases  transmitted  through,  247 

risk  to,  405 
Myxoma  fibrosum  of  placenta,  240 


VTEEVOUS  system,  changes  in,  147 
li  disorders  of,  217 

function  of,  137 
Neuralgia  in  pregnancy,  210 
Newborn  child,  apparent  death  of,  586 

treatment  after  death  of,  587 
Nipple,  81 
Nipples,  depressed,  594 

fissures  and  excoriations  of,  594 
Nursing  women,  diet  of,  592 
Nutrition,  132 


ABTURATOR  membrane,  37 
\J    Occipito-posterior  positions,  333 
Occiput,  rotation  of,  forward,  287 
(Edema  of  lower  limbs,  221 

of  vulva,  376 

Oldham's  vertebral  hook,  523 
Operations,  high  forceps,  507 
Organic  changes,  rigidity  depending  upon, 
368 


Os  innominatum,  33 
occlusion  of,  370 
uteri,  artificial  dilatation  of,  473 
Osteomalacia,  392 

deformity  from,  400 

frequency  of,  393 

[rare  in  the  U.  S-,  393] 
Osteophytes,  formation  of,  147 
Ovarian  tumor,  231 
Ovaries,  74 

tumors  of,  373 
Ovary,  functions  of,  82 

structure  of,  75 

Ovulation  and  menstruation,  82 
Ovule,  79 

escape  of,  83 
Ovum,  cystic  disease  of,  237 

formation  of  cyst  around,  191 

pathology  of,  234 

Oxalate  of  cerium  in  pregnancy,  206 
Oxytocic  remedies,  357 
Oxytocics,  administration  of,  472 


PAINS  during  labor,  271 
effect  of,  on  mother  and  foetus,  272 
irregular  and  spasmodic,  356 
value  of  intermittent  character  of,  270 
Palpation  due  to  sympathetic  disturbance, 

211 

Pampiniform  plexus,  66 
Paralysis  in  pregnancy,  217 

puerperal,  218 
Parturient  canal,  axis  of,  44 
Pelvic  articulations,  36 
cellulitis,  680 

differential  diagnosis  of,  684 
etiology  of,  681 
prognosis  of,  685 
relative  frequency  of,  683 
results  of  physical   examination 

of,  683 
seat  of,  681 

symptomatology  of,  683 
symptoms  of  suppuration  of,  685 
terminations  of,  684 
treatment  of,  686 
variety  of  nomenclature,  680 
joints,  movements  of,  38 
peritonitis,  680 
presentations,  312 
causes  of,  312 
diagnosis  of,  313 
frequency  of,  312 
prognosis  of,  312 
mechanism  of,  315 
treatment  of,  319 
Pelvis,  anatomy  of,  33 
cavitj  of,  46 
contracted,  407 

diagnosis  of,  408 
treatment  of,  411 

[deformed,  symphyseotomy  in,  415] 
deformities  of,  391,  394 
deformity  of,  452 


694 


INDEX. 


Pelvis — 

development  of,   46 

in  different  races,  48 

measurements  of,  41 

obliquely  contracted,  401 

planes  of,  43 

Eobert's,  403 

soft  parts  in  connection  with,  48 

[sometimes  very  small  in  large  women, 

394] 
Perineum,  53 

distention  of,  299 
examination  of,  307 
extreme  rigidity  of,  371 
incision  of,  300 
relaxation  of,  299 
support  of,  299 

Period  of  day  at  which  labor  occurs,  278 
Peripheral  thrombosis,  673 
history  of,  674 
pathology  of,  674 
period  of  commencement  of,  674 
progress  of,  674 
symptoms  of,  673 
treatment  of,  677 
Peritonitis,  pelvic,  680 
[Phlebitis,  crural,   after    Porro-Csesarean 

and  Caesarean  sections,  676] 
Phlegmasia  dolens,  673 
Phthisis,  228 
Placenta,  adherent,  441 

treatment  of,  441 
adhesions,  437 
battledore,  244 
double,  242 

entire  separation  of,  427 
expression  of,  303 
fatty  degeneration  of,  243 
form  of,  115 
functions  of,  120 
membranacea,  241 
pathological  changes  in,  422 
pathology  of,  241 
polypus,  263 
prsevia,  418 

causes  of,  418 
definition  of,  418 
history  of,  418 
prognosis  of,  423 
symptoms  of,  419 
treatment  of,  424 
signs  of  adherent,  441 
souffle,  162 
succenturise,  241 
Placentitis,  241 
Planes  of  pelvis,  43 
Pneumonia,  228 
[Polypus  uteri  as  an  obstruction  to  labor, 

378] 
Porro-Csesarean  operation,  549 

[in  fibroid  obstruction,  373] 
Precipitate  labor  less  common  than  linger- 
ing, 365 
labors,  351 

treatment  of,  366 


Pregnancies,  multiple,  in  Europe,  173 
Pregnancy,  137 

abdominal,  191 

excision  of  cyst  in,  196 

mode  of  performing  operation  in, 
195 

treatment  of,  196 
abnormal,  173 

appearance  of  breasts  in,  153 
auscultatory  signs  of,  158 
ballottement  as  a  sign  of,  157 
classification  of  signs  of,  150 
composition  of  blood  in,  145 
constipation  in,  208 
diabetes  in,  216 
diagnosis  of,  187 
diarrhoea  in,  208 
differential  diagnosis  of,  164 
diseases  coexisting  with,  227 
diseases  of,  203 
dress  of  patient  during,  291 
duration  of,  167 
extra-uterine,  179 

classification  of,  179 
etiology  of,  181 
false  ovarian,  185 
foetal  movements  in,  155 
general   modifications   in    body  pro- 
duced by,  145 
hemorrhoids  in,  209 
insanity  of,  613 

causes  of,  616 

duration  of,  618 

forms  of,  614 

judicious  nursing  in,  622 

post-mortem  signs  of,  618 

prognosis  of,  615,  618 

symptoms  of,  619 

treatment  of;  620,  623 
interstitial,  185 
multiple,  diagnosis  of,  176 
neuralgia  in,  210 
paralysis  in,  217 
progress  of,  185 
protraction  of,  169 
ptyalism  in,  209 
rupture  of,  185 
signs  of,  149 
spurious,  166 
symptoms  of,  149,  185 
termination  of,  185 
treatment  of,  188 
uterine  fluctuation  in,  158 
vaginal  pulsation  in,  158 

signs  of,  157 

Premature  labor,  induction  of,  415 
Presentations,  face,  323 
breech,  312 
complex,  345 
footling,  312 
knee,  312 
pelvic,  312 
transverse,  337 

Princess  Charlotte  of  Wales,  death  of,  364 
Prolapse  of  uterus,  222 


INDEX. 


695 


Prolapsed  funis,  346 

causes  of,  348 
diagnosis  of,  348 
frequency  of,  347 
prognosis  of,  347 
treatment  of,  349 
Prolonged  labors,  351 

evil  effects  of,  352 
Propulsion,  274 
Protracted  labor,  causes  of,  354 
treatment  of,  356 
Protraction  of  pregnancy,  169 
Pruritus  of  vulva,  221 
Ptyalism  in  pregnancy,  209 
Puberty,  changes  occurring  at,  88 
Puerperal  disease,  defective  sanitation  as  a 

cause  of,  633 
eclampsia,  603 

as  a  cause  of  albumin  in  urine, 

214 

cause  of  death  in,  606 
doubtful  etiology  of,  603 
exciting  causes  of,  608 
obstetric  management  in,  611 
paroxysms  during,  611 
pathology  of,  606 
premonitory  symptoms  of,  604 
treatment  of,  609 
fever,  administration  of  turpentine  in, 

655 

application  of  cold  in,  654 
difference  of  opinion  as  to,  623 
evacuant  remedies  in,  655 
history  of,  624 
modern  view  of,  624 
mortality  of,  in  lying-in  hospitals, 

624 
reduction    of    temperature    in, 

653 
theories   advanced   regarding  its 

nature,  626 

theory  of  its  local  origin,  626 
treatment  of,  655 
insanity,  612 

classification  of,  612 
pleuro-pneumonia,  667 

physical  signs  of,  667 
septicaemia,  623 

description  of,  644 
duration  of,  645 
pyaemic  forms  of,  647 
symptoms  of,  644 
treatment  of,  648 
state  and  its  management,  575 

temperature  of,  577 
thrombosis,  656 
cases  of,  663 
cause  of  death  in,  665 
conditions  which  favor,  657 
history  of,  661 
post-mortem  examinations  in,  660, 

665 

symptoms  of,  661 
treatment  of,  665,  668 
[Pullulation,  arrested,  251] 


AUICKENING,  syncope  during  period 
\l    of,  211 

Quinine  as  an  oxytocic,  357 


RESPIRATION,  commencement  of,  586 

II        of  foetus,  133 

Respiratory  organs,  affections  of,  210 

treatment  of,  212 
changes  in,  147 

Rest,  importance  of  prolonged,  585 
Retention  in  utero  of  a  blighted  ovum,  263 

of  urine,  219 
Retroversion,  223 

causes  of,  224 

diagnosis  of,  225 

progress  of,  224 

symptoms  of,  224 

termination  of,  224 

treatment  of,  225 
Rickets,  392 

frequency  of,  393 

mode  of  production  in,  396 
Robert's  pelvis,  403 
Round  ligaments  of  uterus,  71 


OACRO-ILIAC  synchondrosis,  37 
0        -sciatic  ligaments,  37 
Sacrum,  anatomy  of,  35 

mechanical  relations  of,  35 
Salicine  in  pregnancy,  205 
Sanitary  arrangements  in  septicaemia,  633 
Saprsemia  or  self-infection,  sources  of,  629 
Scarlet  fever,  227 
Scybalous  masses  in  intestines,  376 
Secretions  and  excretions,  577 
Semen,  96 

ascent  of,  98 

Septicaemia  from  contagion,  634 
prophylaxy  of,  637 
puerperal,  623 
surgical,  627 

Septic  poison,  nature  of,  638 
Serous  envelope,  114 
Sewer-gas  a  cause  of  septicaemia,  633 
Sex  of  children  in  twin  pregnancies,  174 
Shoulder  presentations,  337 

causes  of,  338 

diagnosis  of,  339 

frequency  of,  339 

mechanism  of,  341 

prognosis  of,  339 

terminations  of,  341 

treatment  of,  344 
Sites  of  impregnation,  98 
Softening  of  cervix,  157 
Spasmodic  cough,  210 
Spondylolisthesis,  397 

[origin,  etc.,  rare  in   the  U.  S.,  399, 

400] 

Spondylolizema,  400 
Spurious  pregnancy,  166 
Stage  of  labor  in  which  delay  odours,  352 
Superfecundation,  176 


696 


INDEX. 


Superfcetation,  176 

Suppuration,  treatment  of  long-continued, 

599 
Symphyseotomy,  553,  557 

description  of  operation,  560 

Galbiati's  knife  used  in,  560 

history  of,  557 

[-knife,  Harris's,  561] 

limits  of  operation  of,  558 

progress  of,  561 

[and  results  of,  563] 
Symphysis  pubis,  37 

Syncope  during  period  of  quickening,  211 
Syphilis,  229 


TACTUS  eruditus,  279 

A     Tetanoid     falciform    constriction     of 

uterus,  371 

Tetanus  in  pregnancy,  219 
Thornton's  ice-cap,  654 
Thrombosis  and  embolism,  distinction  be- 
tween, 659 

puerperal,  656 

Toothache   and   caries  of  teeth   in   preg- 
nancy, 210 

Traction,  method  of,  505 
Transfusion,  secondary  effects  of,  574 
Tubal  abortion,  183 

gestation,  179,  180,  182 
Tumors,  deformity  from,  404 

of  ovaries,  373 

Tumor,  labor  complicated  with,  372 
Tunica  albuginea,  75 
Turning,  426 

[bimanual,  429] 

by  combined    external   and   internal 
manipulation,  485 

dangers  of  operation  of,  480 

history  of,  479 

in  abdomino-anterior  positions,  492 

in  placenta  prsevia,  491 

method  of  performance,  483 
[Twins,  Carolina,  united,  386] 

[duplex,  birth  of,  384] 

locked,  381 

[united,  387] 


TTMBILICAL  cord,  121 
U  pathology  of,  244 

prolapse  of,  346,  405 

souffle,  161 
Urethra,  52 

Urinary  organs,  disorders  of,  219 
Urine,  changes  in,  148 

incontinence  of,  220 

in  intra-uterine  life,  136 

phosphatic  condition  of,  220 

retention  of,  219,  583 
[Uteri,  double,  68] 
Uterine  contraction  after  birth  of  child, 

301 
at  commencement  of  labor,  269 

fluctuation  in  pregnancy,  158 


Uterine  hydatids,  237 

parietes,  changes  in,  141 
pressure,  special  value  of,  361 
souffle,  16^! 

vessels,  changes  in,  579 
Utero-gestation,  period  of,  169 

-sacral  ligaments,  72 
Uterus,  57 

alterations  in  tissues  of,  452 
anatomy  of,  62 
anomalies  of,  67 
changes  in,  137 
contraction  of,  578 
gestation  in  a  bi-lobed,  198 
gravid,  anteversion  of,  223 

displacements  of,  222 

pressure  by,  212 

retroversion  of,  223 
in  protracted  labor,  354 
inversion  of,  462 

acute  and  chronic  pains,  463 

description  of,  463 

differential  diagnosis  of,  464 

mechanism  of,  464 

symptoms  of,  463 

treatment  of,  466 
ligaments  of,  69 

methods  acting  indirectly  on,  472 
partitioned,  69] 
prolapse  of,  222 
round  ligaments  of,  71 
rupture  of,  451 

causes  of,  452 

prognosis  of,  455 

symptoms  of,  454 

treatment  of,  456 
size  of,  at  various  stages  of  pregnancy, 

140 
[spontaneous  reposition  of,  inverted, 

467,  468] 
value  of  anaesthesia  in  relaxing,  493 


yAGINA,  54 
T     bands  and  cicatrices  in,  371 

contraction  of,  580 

lacerations  of,  459 

orifice  of,  52 

plugging  of,  426 
Vaginal  cystocele,  375 

examinations,.  294 

mode  of  conducting,  295 

pulsation  in  pregnancy,  158 

signs  of  pregnancy,  157 
Vectis,  519 

cases  in  which  applicable,  520 

nature  of,  519 
Veins,  death  from  air  in,  671 

lacerations  of,  222 
Venesection,  652 
[Version  by  the  vertex,  336] 

cephalic,  479 

spontaneous,  342 
Vesical  calculus,  375 
Vesicular  mole,  237 


INDEX. 


697 


Vestibule,  51 

Viscera,  modifications  in  certain,  147 

Vulva,  oedema  of,  376 

pruritus  of,  221 

vascular  supply  of,  53 
Vulvo-vaginal  glands,  53 


w 


ALES,  death  of  Princess  Charlotte  of, 
364 


Weaning,  period  of,  593 
Wet-nurse,  selection  of,  590 

[-nurses  of  the  U.  S.,  592] 
[Womanhood,  precocious  physical,  88] 


7YMOTIC  fever,  theory  of  an  essential, 
L        626 

diseases,  infection  from,  631 


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THE  flEDICAL  NEWS===Continued. 

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DIGTIONARY  OF  MEDISINE 

AND  THE  ALLIED  SCIENCES, 

COMPRISING  THE  PRONUNCIATION,   DERIVATION  AND  FULL  EXPLANATION  OF  MEDICAL 

TERMS;  TOGETHER  WITH  MUCH  COLLATERAL  DESCRIPTIVE  MATTER, 
NUMEROUS  TABLES,  ETC. 

By   ALEXANDER    DUANE,  M.  D., 

Assistant  Surgeon  to  the  New  York  Ophthalmic  and  Aural  Institute;  Reviser  of  Medical  Terms  for 
Webster's  International  Dictionary. 

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in  his  endeavor  to  bring  before  the  profession, 
and  especially  the  students  of  medicine,  a  book  em- 
bodying completeness  and  explicitness.  The 
rocabulary  is  abundant  and  its  fulness  is  paral- 
leled by  the  explanation  accorded  each  word.  It 
also  contains  extensive  tables.  Each  word  is  fol- 
lowed by  its  correct  pronunciation,  a  new  feature 
in  works  of  this  kind,  given  by  means  of  a  simple 
and  obvious  phonetic  spelling.  Derivation,  the 
greatest  aid  to  memory,  is  fully  treated  of,  and  for 
the  convenience  of  those  who  do  not  understand 
Greek,  the  English  letters  are  substituted  for 
those  of  the  Greek  in  giving  the  roots  of  the  words 


From  A.  L.  LOOMIS,  M.  D.,  Professor  Patholoqy  and 
Practice  of  Medicine,  Medical  Department,  Univer- 
sity City  of  New  York,  New  York. 
It  seems  to  me  entirely  satisfactory  for  the  pur- 
pose for  which  it  is  intended. 
From  J.  C.  WILSON,  M.  D.,  Professor  of  Medicine, 
Jefferson  Medical  College,  Philadelphia. 
It  appears  to  be  well  suited  to  the  purposes  ol 
the  medical  student,  being  simple  as  regards  deri- 
vations and  pronunciation,  explicit  yet  sufficiently 
comprehensive  in  definitions,  and  thoroughly  up 
to  the  times. 

From  JAMES  T.  WHITTAKEB,  M.  D.,  Professor  Theory 


and  Practice  of  Medicine,  Medical  College  of  Ohio, 
Cincinnati,  O. 


derived  from  that  language.    The  author's  expe- 
rience as  a  lexicographer  is  fully  attested  by  his 

position  as  Reviser  of  Medical  Terms  for  Web-  „ r 

ster's  International  Dictionary.  We  predict  that  I  dents,  and  thoroughly  modern  in  every  particular 
this  will  become  a  standard  and  favorite  work  of  i  in  which  I  have  taken  occasion  to  consult  it.  I 
its  class. — Medical  Fortnightly.  \  shall  certainly  recommend  it  to  my  class. 


I  find  it  admirably  adapted  to  the  wants  of  stu- 


THE   STUDENTS'  QUIZ  SERIES. 

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ant Surgeon.  Out-Patient  Department,  Roose- 
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DISEASES  OF  CHI  LDREN-By  C.  A.  RHODM, 
M.  D.,  Instructor  in  Diseases  of  Children,  New 
York  PcstrGraduate  Medical  College.  81. 


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Dictionaries. 


TWENTY-FIRST    EDITION.       THOROUGHLY    REVISED. 

Dunglison's  Dictionary 

OF   MEDICAL  SCIENCE. 

With  the  Pronunciation.  Accentuation  and  Derivation  of  the  Terms. 

Containing  a  full  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology) 
Medical  Chemistry,  Pharmacology,  Pharmacy,  Therapeutics,  Medicine,  Hygiene,  Dietet- 
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M.  D.,  late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Phila- 
delphia. New  (21st)  edition,  thoroughly  revised  and  greatly  enlarged.  With  the  Pro- 
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THIS  great  medical  dictionary,  which  has  been  for  more  than  two  generations  the 
standard  of  the  English-speaking  race,  is  now  issued  in  a  thoroughly  revised  and 
greatly  enlarged  and  improved  edition.  The  new  words  and  phrases  aggregate 
by  actual  count  over  44,OOO.  Though  the  new  edition  contains  far  more  matter  than  its 
predecessor,  the  whole  is  accommodated  within  a  volume  convenient  for  the  hand. 

The  revision  has  not  only  covered  every  word,  but  it  has  resulted  in  a  number  of 
important  new  features  designed  to  confer  on  the  work  the  utmost  usefulness,  and  to  make 
it  answer  the  most  advanced  demands  of  the  times. 

Pronunciation  has  been  introduced  throughout  by  means  of  a  simple  and  obvious 
system  of  phonetic  spelling.  At  a  glance  the  proper  sound  of  a  word  is  clearly  indicated, 
and  thus  a  most  important  desideratum  is  supplied. 

Derivation  affords  the  utmost  aid  in  recollecting  the  meanings  of  words,  and  gives 
the  power  of  analyzing  and  understanding  those  which  are  unfamiliar.  It  is  indicated  in 
the  simplest  manner.  Greek  words  are  spelled  with  English  letters,  and  thus  placed  at 
the  command  of  those  unfamiliar  with  the  Greek  alphabet. 

Definitions,  the  essence  of  a  dictionary,  are  clear  and  full,  a  characteristic  in 
which  this  work  has  always  been  preeminent.  In  this  edition  much  explanatory  and 
encyclopedic  matter  has  been  added,  especially  upon  subjects  of  practical  importance.  Thus 
under  the  various  diseases  will  be  found  their  symptoms,  treatment,  etc. ;  under  drugs  their 
doses  and  effects,  etc.,  etc.  A  vast  amount  of  information  has  been  clearly  and  conveniently 
condensed  into  tables  in  the  alphabet. 

In  a  word,  Dunglison's  Medical  Dictionary,  in  its  remodelled  and  enlarged  shape,  is 
equal  to  all  that  the  student  and  practitioner  can  expect  from  such  a  work. 


The  new  "  Dunglison"  is  new  indeed.  The  vast 
amount  of  new  matter  and  the  thoroughness  with 
which  the  work  has  been  brought  down  to  date 
cannot  fail  to  strike  even  the  least  observant 
reader.  The  immense  advances  made  in  all 
branches  of  medical  science  here  find  represen- 
tation. A  prominent  and  very  useful  feature  of 
the  old  book  is  retained  and  amplified  in  this— we 
mean  the  tables,  which  recur  with  great  fre- 
quency and  represent  a  vast  amount  of  condensed 
information.  In  respect  to  accuracy  the  book  quite 


the  existing  condition  of  medical  science.  Thus, 
under  the  heading  Hernia,  besides  the  definition 
of  the  condition,  a  condensed  table  is  given  of 
the  various  forms,  and  a  brief  resutnfi  is  given  of 
the  therapeutical  indications.  Under  the  heading 
Murmurs,  besides  a  description  of  the  various 
forms,  a  table  is  given  of  the  significance  of  the 
murmurs  of  valvular  origin.  Under  Bacteria  the 
leading  classifications  are  recorded,  and  a  para- 
graph is  devoted  to  the  question  of  the  determina- 
tion of  the  pathogenic  properties,  and  another  to 


equals  and  usually  surpasses  any  of  its  contempo-    modes  of  culture  of  the  bacteria. — The  Montreal 

raries  that  we  are  acquainted  with.    The  American  '  Medical  Journal,  June,  1894. 

Journal  of  the  Medical  Sciences,  Jan.,  1894.  |      So  fully  have  derivations  and  definitions  been 

Covering  the  entire  field  of  medicine,  surgery  j  considered,  and  so  great  is  the  amount  of  prac- 
and  the  collateral  sciences,  its  range  of  usefulness  j  tical  matter,  such  as  symptoms,  treatment  and 
can  scarcely  be  measured.  Perhaps  the  most  valu-  prognosis  of  many  of  the  diseases  described,  that 
able  feature  in  the  present  work  is  the  addition  of  the  volume  is  entitled  to  be  called  an  encyclo- 
a  vast  amount  of  practical  matter.  The  type  is  ;  pedia  rather  than  a  dictionary. — The  Brooklyn 
com mendably  clear. — Medical  Record,  Feb.  24, 1894.  |  Medical  Journal,  June,  1894. 

The  new  subjects  and  terms  treated  are  no  less  !  A  thorough  system  of  phonetic  spelling  gives 
than  forty-four  thousand,  sufficient  in  themselves  the  pronunciation  of  all  words  that  are  not  so  sim- 
to  form  a  large  volume.  There  has  been  a  praise-  pie  as  to  require  no  key. — New  Orleans  Medical  and 
worthy  attempt  to  render  the  work  an  epitome  of  Surgical  Journal,  June,  1894. 


The  National  Medical  Dictionary, 

Including  English,  French,  German,  Italian  and  Latin  Technical  Terms  used  in 
Medicine  and  the  Collateral  Sciences,  and  a  Series  of  Tables  of  Useful  Data.  By  JOHN 
S.  BILLINGS,  M.  D.,  LL.  D.,  Edin.  and  Harv.,  D.  C.  L.,  Oxon.,  member  of  the  National 
Academy  of  Sciences,  Surgeon  U.  S.  A.,  etc.  In  two  very  handsome  royal  octavo  volumes 
containing  1574  pages,  with  two  colored  plates.  Per  volume— cloth,  $6.00:  leather,  $7.00; 
half  morocco,  marbled  edges,  $8.50.  Subscription  only.  Address  the  publishers. 

Apart  from  the  boundless  stores  of  information  ;  chief  modern  languages.  There  cannot  be  two 
whichmay  be  gained  by  the  study  of  a  good  diction-  !  opinions  as  to  the  great  value  of  this  dictionary  as 
ary,  one  is  enabled  by  the  work  under  notice  to  read  [  a  book  of  ready  reference  for  all  sorts  and  condi- 
intelligentlyany  technical  treatise  in  any  of  the  four  •  tions  of  medical  men. — London  Lancet. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Anatomy,  Dictionary. 


THIRTEENTH  EDITION. 


IN    COLORS    OR    IN    BLACK. 

Anatomy,  Descriptive  and  Surgical, 

BY  HENRY  GRAY,  P.  R.  S., 

LECTURER  ON  ANATOMY  AT  ST.  GEORGE'S  HOSPITAL,  LONDON. 

EDITED  BY  T.  PICKERING  PICK,  F.  R.  C.  S., 

Surgeon  to  and  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy, 
Royal  College  of  Surgeons  of  England. 

A  new  American  from  the  thirteenth  enlarged  and  improved  London  edition.    In  one 

imperial  octavo  volume  of  1118  pages,  with  636  large  and  elaborate  engravings 

on   wood.     Price,  with  illustrations  in  colors,  cloth,  $7  ;  leather,  $8. 

Price^  with   illustrations    in    black,   cloth,   $6;    leather,   $7. 

SINCE  1857  Gray's  Anatomy  has  been  the  standard  work  used  by  students  of 
medicine  and  practitioners  in  all  English-speaking  race^.  So  preeminent  has  it 
been  among  the  many  works  on  the  subject  that  thirteen  editions  have  been 
^required  to  meet  the  demand.  This  opportunity  for  frequent  revisions  has  been 
fully  utilized  and  the  work  has  thus  been  subjected  to  the  careful  scrutiny  of  many  of  the 
most  distinguished  anatomists  of  a  generation,  whereby  a  degree  of  completeness  and  ac- 
curacy has  been  secured  which  is  not  attainable  in  any  other  way.  In  no  former  revision 
has  so  much  care  been  exercised  as  in  the  present  to  provide  for  the  student  all  the 
assistance  that  a  text-book  can  furnish.  The  engravings  have  always  formed  a  distin- 
guishing feature  of  this  work,  and  in  the  present  edition  the  series  has  been  enriched  and 
rendered  complete  by  the  addition  of  many  new  ones.  The  large  scale  on  which  the 
illustrations  are  drawn  and  the  clearness  of  the  execution  render  them  of  unequalled 
value  in  affording  a  grasp  of  the  complex  details  of  the  subject.  As  heretofore  the  name 
of  each  part  is  printed  upon  it,  thus  conveying  to  the  eye  at  once  the  position,  extent 
and  relations  of  each  organ,  vessel,  muscle,  bone  or  nerve  with  a  clearness  impossible 
when  figures  or  lines  of  reference  are  employed.  Distinctive  colors  have  been  utilized 
to  give  additional  prominence  to  the  attachments  of  muscles,  the  veins,  arteries 
and  nerves.  For  the  sake  of  those  who  prefer  not  to  pay  the  slight  increase  in  cost 
necessitated  by  the  use  of  colors,  the  volume  is  published  also  in  black  alone. 

The  illustrations  thus  constitute  a  complete  and  splendid  series,  which  will  greatly 
assist  the  student  in  forming  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room.  Combining  as  it  does  a  complete  Atlas  of  Anatomy 
with  a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy,  the  work  covers 
a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary  text-books.  It  not 
only  answers  every  need  of  the  student  in  laying  the  groundwork  of  a  thorough  medical 
education,  but  owing  to  its  application  of  anatomical  details  to  the  practice  of  medicine 
and  surgery,  it  also  furnishes  an  admirable  work  of  reference  for  the  active  practitioner. 

We  always  had  a  kindly  regard  for  the  illustra- 
tions in  Gray,  where  each  organ,  tissue,  artery,  and 
nerve  bear  their  respective  names,  and  in  this  edi- 
tion color  has  been  worked  to  advantage  in  bring- 
ing out  the  relationship  of  vessel  and  nerve.  Of  late 


have  more  than  one  need  to  ask  which  one  to  add. 
The  work  is  admitted  to  be  easily  first  on  anatomy 
in  any  language. —  TheAmer.  Practitioner  and  News. 
Teachers  of  anatomy  are  almost  unanimous  in 
recommending  "Gray"  as  the  standard  work  for 


years,  many  works  on  anatomy  have  been  intro-  j  the  student.    The  illustrations  are  conceded  to  be 
duced  to  the  profession,  but  as  a  reference  book  for    the  best  that  have  yet  been  given  to  the  profes- 
the  practical  everyday  physician,  and  as  a  text-book    sion.    In  short,  Grray's  Anatomy  is  the  ideal  text- 
for  the  student,  we  think  it  will  be  difficult  to  sup-    book  on  this  subject.— Clevela nd  Wed.  Gazette. 
plant  Gray.— Buffalo  Med.  and  Surg.  Journal.  I     Gray's   has  been    the  unvarying  standard   for 

It  has  thoroughly  and  completely  established  ]  anatomical  study  by  the  vast  majority  of  English- 
itself  as  the  anatomy,  par  excellence.— Brooklyn  I  speaking  medical  students  for  so  long  that  it 
Medical  Journal,  \  would  seem  an  anomaly  to  see  a  student  acquire 

"    such  knowledge  from  some  other  source. — Medi- 


It  embraces  the  whole  of  human  anatomy,  and 
it  particularly  dwells  on  the  practical  or  applied 
part  of  the  subject,  so  that  it  forms  a  most  useful, 
intelligible  and  practical  treatise  for  the  student 
and  general  practitioner.—  Dublin  Journal  of  Medi- 
cal Science , 

In  modern  times  no  book  on  any  medical  sub- 
ject has  held  the  position  of  a  standard  so  long  as 
Gray's  Anatomy.  For  logical  arrangement,  clear, 
terse,  pointed,  and  yet  full  description,  it  is  the 
peer  of  any  work  on  any  scientific  subject.  A 
pioneer  in  helpful  drawings,  it  is  still  in  the  van 
and  leads  in  every  improvement.  The  physician  or 
student  who  requires  but  one  work  on  anatomy 
will  not  need  to  ask  which,  nor  will  those  who  will 


cal  Fortnightly. 

The  matchlecs  book  of  the  doctor's  or  surgeon's 
library  is  and  has  been  Gray's  Anatomy.  Since 
1857  it  has  held  the  lead  ing  place  in  all  colleges  as 
a  text-book  and  has  been  the  one  central  figure  in 
the  many  text-books  in  anatomy  that  have  claimed 
attention.  It  is  still  the  standard  text-book.—  The 
Kansas  Cif>/  Medicnl  Inder. 

The  careful  scrutiny  to  which  It  has  been  sub- 
jected in  forty  years,  and  the  successive  issues  of 
thirteen  editions  have  made  it  what  it  is  to-day, 
the  most  perfect  work  of  its  kind  extant.—  tfnf- 
versity  Medical  Magazint. 


HOBLYN'S  DICTIONARY  OF  MEDICINE.  A  Dictionary  of  the  Terms  Used  in  Medicine  and  the 
Collateral  Sciences.  By  RICHARD  D.  HOBI.TN,  M.  D.  In  one  large  royal  12mo.  volume  of  520  double- 
columned  pages.  Cloth,  fl.50;  leather,  ?2.00. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


6  Anatomy,  Physiology. 

HUMAN    MONSTROSITIES 

BY    BARTON    C.    HIRST,    M.D.,     AND     GEORGE    A.    PIERSOL,    M.D 

Professor  of  Obstetrics  in  the  University  Professor  of  Anatomy  and  Embryology 

of  Pennsylvania.  in  the  University  of  Pennsylvania. 

Magnificent  folio,  containing  220  pages  of  text,  illustrated  with  engravings,  and 
39  full- page,  photographic  plates  from  nature.  In  four  parts,  price,  each,  $5.  Limited 
edition,  for  sale  by  subscription  only.  Address  the  Publishers. 

We  have  before  us  the  fourth  and  last  part  of    must  always  retain  the  honor  of  being  the  first  of 


the  latest  and  best  work  on  human  monstrosi- 


its  kind  written  in  the  English  language. — The 


tit's.  This  completes  one  of  the  masterpieces  of  j  British  Medical  Journal. 
American  medical  literature.  Typographically  |  This  work  promises  to  be  one  for  which  a  place 
and  from  an  artistic  standpoint,  the  work  is  un-  '  must  be  found  in  the  library  of  every  anatomist, 
exceptionable.  In  this  last  and  final  volume  pathologist,  obstetrician  and  teratologifet.  It  is  the 
is  presented  the  most  complete  bibliography  of  joint  production  of  an  obstetrician,  and  an  embry- 
teratological  literature  extant.  No  library  will  be  ologist,  and  hietologist,  and  this  fact  makes  it 
complete  without  this  magnificent  work. — Jour- 


nal of  the  American  Medical  Association. 

Altogether,  Human  Monstrosities  is  a  satisfactory 
production.  It  will  take  its  place  as  a  standard 
work  on  teratology  in  medical  libraries,  and  it 


certain  that  both  the  obstetric  and  anatomical 
sides  of  the  subject  will  be  fully  represented  and 
described.  The  book  promises  to  be  one  of  the 
greatest  value  to  the  English-speaking  medica> 
world. — Edinburgh  Medical  Journal. 


Allen's  System  of  Human  Anatomy. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  By  HARRISON 
ALLEN,  M.  D.,  Professor  of  Physiology  in  the  University  of  Pennsylvania.  With  an 
Introductory  Section  on  Histology  by  E.  O.  SHAKESPEARE,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Price  per  Section,  $3.50 ; 
also  bound  in  one  volume,  cloth,  $23.00 ;  very  handsome  half  Russia,  raised  bands  and 
open  back,  $25.00.  For  sale  by  subscription  only.  Address  the  Publishers. 

Holden's  Landmarks,  Medical  and  Surgical. 

Landmarks,  Medical  and  Surgical.  By  LUTHER  HOLDEN,  F.  E.  C.  S.. 
Surgeon  to  St.  Bartholomew's  Hospital,  London.  Second  American  from  the  third  and 
revised  English  ed.,  with  additions  by  W.  W.  KEEN,  M.  D.,  Professor  of  Artistic  Anatomy 
in  the  Penna.  Academy  of  Fine  Arts.  In  one  12mo.  volume  of  148  pages.  Cloth,  $1.00. 

Clarke  &  Lockwood's  Dissector's  Manual. 

The  Dissector's  Manual.  By  W.  B.  CLARKE,  F.  E.  C.  S.,  and  C.  B.  LOCK- 
WOOD,  F.  E.  C.  S.,  Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical 
School,  London.  In  one  pocket-size  12mo.  volume  of  396  pages,  with  49  illustrations. 
Limp  cloth,  red  edges,  $1.50.  See  Students'  Series  of  Manuals,  page  30. 

Messrs.Clarke  and  Lockwood  have  written  abook  |  intimate  association  with  students  could  have 
that  can  hardly  be  rivalled  as  a  practical  aid  to  the  given.  With  such  a  guide  as  this,  accompanied 
dissector.  Their  purpose,  whicn  is  "how  to  de-  by  so  attractive  a  commentary  as  Treves'  Surgical 
scribe  the  best  way  to  display  the  anatomical  Applied  Anatomy  (same  series),  no  student  could 
structure,"  has  been  fully  attained.  They  excel  in  fail  to  be  deeply  and  absorbingly  interested  in  the 
a  lucidity  of  demonstration  and  graphic  terseness  study  of  anatomy. — New  Orleans  Medical  and  Sur- 
of  expression,  which  only  a  long  training  and  gical  Journal. 

Treves'  Surgical  Applied  Anatomy. 

Surgical  Applied  Anatomy.  By  FREDERICK  TREVES,  F.  E.  C.  S.,  Senior 
Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital.  In  one  pocket- 
size  12mo.  volume  of  540  pages,  with  61  illustrations.  Limp  cloth,  red  edges,  $2.00.  See 
Students'  Series  of  Manuals,  p.  30. 

Bellamy's  Surgical  Anatomy. 

The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  Important  Surgical  Eegions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
Operative  Surgery.  By  EDWARD  BELLAMY,  F.  E.  C.  S.,  Senior  Assistant-Surgeon  to  the 
Charing- Cross  Hospital.  In  one  12mo.  vol.  of  300  pages,  with  50  illus.  Cloth,  $2.25. 

Wilson's  Human  Anatomy. 

A  System  of  Human  Anatomy,  General  and  Special.  By  ERASMUS 
WILSON,  F.  E.  S.  Edited  by  W.  H.  GOBRECHT,  M.  D.,  Professor  of  General  and  Surgical 
Anatomy  in  the  Medical  College  of  Ohio.  In  one  large  and  handsome  octavo  volume 
of  616  pages,  with  397  illustrations.  Cloth,  $4.00;  leather,  $5.00. 


HARTSHORNE'S  HANDBOOK  OF  ANATOMY 
AND  PHYSIOLOGY.  Second  edition,  revised. 
12mo.,  310  pages,  220  woodcuts.  Cloth,  $1.75. 

HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 


OGY.   Eighth  edition.    In  two  octavo  volumes 
of  1007  T>agp«.  with  320  woodcuts.     Cloth.  S6.0O. 
CLELAND'S  DIRECTORY  FOR  THE  DISSEC- 
TION OF  THE  HUMAN  BODY.   12mo.,  178  ppk 
Cloth,  $1.25. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Physics,  Physiology,  Anatomy,  Chemistry.        7 


Draper's  Medical  Physics. 

Medical  Physics.  A  Text-book  for  Students  and  Practitioners  of  Medicine. 
By  JOHN  C.  DRAPER,  M.  D.,  LL.  D.,  Prof,  of  Chemistry  in  the  Univ.  of  the  City  of 
New  York.  In  one  octavo  vol.  of  734  pages,  with  376  woodcuts,  mostly  original.  Cloth,  $4. 

No  man  in  America  was  better  fitted  than  Dr. 
Draper  for  the  task  he  undertook  and  he  has  pro- 
vided the  student  and  practitioner  of  medicine 
with  a  volume  at  once  readable  and  thorough. 
Even  to  the  student  who  has  some  knowledge  of 
physics  this  book  is  useful,  as  it  shows  him  its 
applications  to  the  profession  that  he  has  chosen. 
Dr.  Draper,  as  an  old  teacher,  knew  well  the  diffi- 


culties to  be  encountered  in  bringing  his  subject 
within  the  grasp  of  the  average  student,  and  that 
he  has  succeeded  so  well  proves  once  more  that 
the  man  to  write  for  and  examine  students  is  the 
one  who  has  taught  and  is  teaching  them.  The 
book  is  well  printed  and  fully  illustrated,  and  in 
every  way  deserves  grateful  recognition. — The 
Montreal  Medical  Journal. 


Reichert's  Physiology.— Preparing. 

A  Text-Book  on  Physiology.  By  EDWARD  T.  REICHERT,  M.  D.,  Professor 
of  Physiology  in  the  University  of  Pennsylvania,  Philadelphia.  In  one  very  handsome 
octavo  volume  of  800  pages,  fully  illustrated. 

Power's  Human  Physiology.— Second  Edition. 

Human  Physiology.  By  HENRY  POWER,  M.  B.,  F.  R.  C.  S.,  Examiner  in 
Physiology,  Koyal  College  of  Surgeons  of  England.  Second  edition.  In  one  12mo.  vol. 
of  509  pp.,  with  68  illustrations.  Cloth,  $1.50.  See  Students'  Series  of  Manuals,  p.  30. 

Robertson's  Physiological  Physics. 

Physiological  Physics.  By  J.  MCGREGOR  ROBERTSON,  M.  A.,  M.  B., 
Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow.  In  one  12mo.  volume  of 
537  pages,  with  219  illus.  Limp  cloth,  $2.  See  Students'  Series  of  Manuals,  page  30. 

The  title  of  this  work  sufficiently  explains  the  I  ments.  It  will  be  found  of  great  value  to  the 
nature  of  its  contents.  It  is  designed  as  a  man-  ;  practitioner.  It  is  a  carefully  prepared  book  of 
ual  for  the  student  of  medicine,  an  auxiliary  to  j  reference,  concise  and  accurate,  and  as  such  we 
his  text-book  in  physiology,  and  it  would  be  particu-  heartily  recommend  it. — Journal  of  the  American 
larly  useful  as  a  guide  to  his  laboratory  expert-  j  Medical  Association. 


Dalton  on  the  Circulation  of  the  Blood. 

Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physio- 
logical Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  By  JOHN  C. 
DALTON,  M.  D.,  Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Sur- 
geons, New  York.  In  one  handsome  12mo.  volume  of  293  pages.  Cloth,  $2. 

ation  for  those  plodding  workers  of  olden  times, 


Dr.  Dal  ton's  work  is  the  fruit  of  the  deep  research 
of  a  cultured  mind,  and  to  the  busy  practitioner  it 
cannot  fail  to  be  a  source  of  instruction.  It  will 
inspire  him  with  a  feeling  of  gratitude  and  admir- 


who  laid  the  foundation  of  the  magnificent  temple 
of  medical  science  as  it  now  stands.— New  Orleans 
Medical  and  Surgical  Journal. 


Bell's  Comparative  Anatomy  and  Physiology. 

Comparative  Anatomy  and  Physiology.  By  F.  JEFFREY  BELL,  M.  A., 
Professor  of  Comparative  Anatomy  at  King's  College,  London.  In  one  12mo.  vol.  of  561 
pages,  with  229  illustrations.  Lim  p  cloth,  $2.  See  Students'  Series  of  Manuals,  page  30. 

The  manual  is  preeminently  a  student's  book—    it  the  best  work   in   existence   in   the  English 
clear  and  simple  in  language  and  arrangement,    language  to  place  in  the  hands  of  the   medical 
It  is  well  and  abundantly  illustrated,  and  is  read-    student.— Bristol  Medico-Chirurgical  Journal. 
able  and  interesting.    On  the  whole  we  consider 


Ellis'  Demonstrations  of  Anatomy.— Eighth  Edition. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  of  the 
Human  Body  by  Dissection.  By  GEORGE  VINER  ELLIS,  Emeritus  Professor  of  Anatomy 
in  University  College,  London.  From  the  eighth  and  revised  London  edition.  In  one 
very  handsome  octavo  volume  of  716  pages,  with  249  illus.  Cloth,  $4.25 ;  leather,  $5.26. 

Roberts'  Compend  of  Anatomy. 

The  Compend  of  Anatomy.  For  use  in  the  dissecting-room  and  in  pre- 
paring for  examinations.  By  JOHN  B.  ROBERTS,  A.  M.,  M.  D.,  Lecturer  in  Anatomy  in 
the  University  of  Pennsylvania.  In  one  16mo.  vol.  of  196  pages.  Limp  cloth,  75  cents. 


WOHLER'S  OUTLINES  OF  ORGANIC  CHEM- 
ISTRY. Edited  by  FITTIO.  Translated  by  IBA 
REMSEN,  M.  D.,  Ph.  D.  In  one  12mo.  volume  of 
650  pages.  Cloth,  $3. 

LEHMANN'S  MANUAL  OF  CHEMICAL  PHYS- 
IOLOGY. In  one  octavo  volume  of  327  pages, 
with  41  illustrations.  Cloth,  $2.26. 


CARPENTER'S  HUMAN  PHYSIOLOGY.  Edited 
by  II  KN  KV  POWER.  In  one  octavo  volume. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 
ABUSE  or  ALCOHOLIC  LIQUORS  IN  HBALTH  AND  Dls- 
KABE.  With  explanations  of  scientific  words.  Small 
12mo.  178  pages.  Cloth,  60  cents. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street.  Philadelphia. 


8 


Physiology— (Continued),  Chemistry. 


Foster's  Physiology.— Fifth  American  Edition. 

Text-Book  of  Physiology.  By  MICHAEL  FOSTER,  M.  D.,  F.  E.  S.,  Prelec- 
tor in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England.  Fifth  and 
enlarged  American  from  the  fifth  and  revised  English  edition,  with  notes  and  additions, 
In  one  handsome  octavo  vol.  of  1064  pages,  with  316  illus.  Cloth,  $4.50;  leather,  $5.50. 
It  is  unquestionably  the  standard  text  book_on  impressed  with  the  care  that  the  author  has  be- 
stowed upon  it.  Apparently  nothing  that  is  known 


physiology  for  students  and  practitioners.  The 
moderate  price  of  this  well-issued  book  at  once 
shows  how  popular  the  work  has  become.  The 
style  is  plain  enough  even  for  the  beginner;  the 


up  to  the  present  year  concerning  vital  processes 
has  escaped  his  painstaking  attention.  The  details 
receive  the  fullest  consideration.  The  additions 


details  are  sufficient  for  the  teacher;  and  the  which  have  been  made  to  this  last  edition  are 
manner  of  dealing  with  the  topics  is  well-ar-  |  caused  by  an  effort  to  explain  more  fully  ana  at 
ranged  for  the  advantage  of  the  practitioner. —  |  greater  length  what  seemed  to  be  the  most  fun da- 
Virginia  Medical  Monthly,  January,  1894.  j  mental  and  important  topics.  The  publishers 

Foster's  Physiology  is  an  accepted  text-book  in  |  have  subjected  it  to  the  searching  revision  of  one 
almost  every  medical  college  in  this  country,  and  |  of  the  foremost  American  professors  of  physio- 
already  commended  to  all  medical  students.  For  ]  logy.  We  have  nothing  but  words  of  the  highest 
the  physician  who  aims  to  keep  abreast  of  all  that  i  praise  for  the  classical  and  thorough  manner  in 
is  new  that  is  true  in  medicine,  a  work  like  this  ;  which  the  work  is  written,  as  well  as  for  the  liber- 
is  a  necessity.  The  illustrations  are  excellent  and  \  ality  of  the  publishers  for  selling  such  a  large 
are  well  printed. —  The  Cincinnati  Lancet-Clinic,  <  work,  and  one  which  must  necessarily  be  very 
June  9,  1894.  costly  to  produce,  for  an  extremely  moderate 

One  cannot  read  a  single  chapter  without  being    price. — The  Canada  Medical  Record,  March,  1894. 


Dalton's  Physiology.— Seventh  Edition. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students 
and  Practitioners  of  Medicine.  By  JOHN  C.  DAI/TON,  M.  D.,  Professor  of  Physiology  in 
the  College  of  Physicians  and  Surgeons,  New  York,  etc.  Seventh  edition,  thoroughly 
revised  and  rewritten.  In  one  very  handsome  octavo  volume  of  722  pages,  with  252  beau- 
tiful engravings  on  wood.  Cloth,  $5.00 ;  leather,  $6.00. 


From  the  first  appearance  of  the  book  it  has 
been  a  favorite,  owing  as  well  to  the  author's 
renown  as  an  oral  teacher  as  to  the  charm  of 
simplicity  with  which,  as  a  writer,  he  always 
succeeds  in  investing  even  intricate  subjects. 
It  must  be  gratifying  to  him  to  observe  the  fre- 
quency with  which  his  work,  written  for  students 
and  practitioners,  is  quoted  by  other  writers  on 
physiology.  This  fact  attests  its  value,  and,  in 
great  measure,  its  originality.  It  now  needs  no 
such  seal  of  approbation,  however,  for  the  thou- 
sands who  have  studied  it  in  its  various  editions 


have  never  been  in  any  doubt  as  to  its  sterling 
worth.— N.  Y.  Medical  Journal. 

Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 
which  it  could  be  reviewed  in  the  ordinary  sense. 
The  work  is  eminently  one  for  the  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 
of  physiology  which  have  a  direct  bearing  on  the 
diagnosis  and  treatment  of  disease.  The  work  is 
one  which  we  can  highly  recommend  to  all  our 
readers. — Dublin  Journal  of  Medical  Science. 


Chapman's  Human  Physiology. 


A  Treatise  on  Human  Physiology.  By  HENRY  C.  CHAPMAN,  M.  D., 
Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 
In  one  octavo  volume  of  925  pages,  with  605  engravings.  Cloth,  $5.50;  leather,  $6.50. 

It  represents  very  fully  the  existing  state  of  j  nical  matters  are  given  in  minute  detail;  elabo- 
physiology.  The  present  work  has  a  special  value  rate  directions  are  stated  for  the  guidance  of  stu- 
to  the  student  and  practitioner  as  devoted  more  dents  in  the  laboratory.  In  every  respect  the 
to  the  practical  application  of  well-known  truths  [  work  fulfils  its  promise,  whether  as  a  complete 
which  the  advance  of  science  has  given  to  the  treatise  for  the  student  or  for  the  physician ;  for 
profession  in  this  department,  which  may  be  con-  I  the  former  it  is  so  complete  that  he  need  look  no 
sidered  the  foundation  of  rational  medicine. — Buf-  farther,  and  the  latter  will  find  entertainment  and 
falo  Medical  and  Surgical  Journal.  I  instruction  in  an  admirable  book  of  reference.— 

Matters  which  have  a  practical  bearing  on  the  |  North  Carolina  Medical  Journal. 
practice  of  medicine  are  lucidly  expressed;   tech-  i 


Schofield's  Elementary  Physiology. 

Elementary  Physiology  for  Students.  By  ALFRED  T.  SCHOFIELD, 
M.  D.,  Late  House  Physician  London  Hospital.  In  one  12mo.  volume  of  380  pages,  with 
227  engravings  and  2  colored  plates  containing  30  figures.  Cloth,  $2.00. 


Frankland  &  Japp's  Inorganic  Chemistry. 

Inorganic  Chemistry.  By  E.  FRANKLAND,  D.  C.  L.,  F.  E.  S.,  Professor  of 
Chemistry  in  the  Normal  School  of  Science,  London.,  and  F.  E.  JAPP,  F.  I.  C.,  Assistant 
Professor  of  Chemistry  in  the  Normal  School  of  Science,  London.  In  one  handsome 
octavo  volume  of  677  pages  with  51  woodcuts  and  2  plates.  Cloth,  $3.75  ;  leather,  $4.75. 


Clowes'  Qualitative  Analysis.— Third  Edition. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  By  FRANK  CLOWES,  D.  Sc.,  London,  Senior  Science-Master 
at  the  High  School,  Newcastle-under-Lyme,  etc.  Third  American  from  the  fourth  and 
revised  English  edition.  la  one  12mo.  vol.  of  387  pages,  with  55  illus.  Cloth,  $2.50. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Chemistry — (Continued). 


Simon's  Chemistry.— New  (5th)  Edition.    Just  Ready. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Begin- 
ners in  Chemistry.  A  Text-book  specially  adapted  for  Students  of  Pharmacy  and  Medi- 
cine. By  W.  SIMON,  Ph.  D.,  M.  D.;  Professor  of  Chemistry  and  Toxicology  in  the  College 
of  Physicians  and  Surgeons,  Baltimore,  and  Professor  of  Chemistry  in  the  Maryland  Col- 
lege of  Pharmacy.  New  (5th)  edition.  In  one  8vo.  vol.  of  501  pp.,  with  44  woodcute  and 
8  colored  plates  illustrating  64  of  the  most  important  chemical  tests.  Cloth,  $3.25. 


The  exhaustion  of  the  very  large  fourth  edition 
In  less  than  two  years  indicates  ihe  leading  posi- 
tion achieved  by  Professor  Simon's  Chemistry  as  a 
text-book  in  medical  and  pharmaceutical  colleges. 
It  furnishes  an  admirable  selection  of  material 
bearing  upon  the  laws  and  phenomena  of  chem- 


referred  to  this  series  of  colors  and  color  changes. 
The  new  edition  has  been  most  carefully  revised 
in  accordance  with  the  advance  of  science  and  in 
order  to  bring  it  into  complete  harmony  with  the 
new  Pharmacopoeia.  All  chemicals  mentioned  in 
the  last  issue  of  that  work  are  included.  Special 


istry.  As  an  aid  to  laboratory  work  a  number  of  j  care  has  been  taken  to  detail  the  most  modern 
experiments  have  been  added.  Physicians  as  well  methods  for  chemical  examination  in  clinical 
as  students  will  aopreciate  the  value  of  the  colored  diagnosis.  The  author's  experience  as  a  physician 
plates  of  reactions,  which  give  a  permanent  and  j  and  as  a  teacher  of  medical  and  pharmaceutical 
accurate  series  of  standards  for  comparison  of  i  students  is  reflected  in  the  special  adaptation  of 
tests,  a  matter  not  susceptible  of  satisfactory  his  book  to  the  needs  of  all  concerned  with  the 


explanation  in  words.  In  medical  practice  im- 
portant pathological  and  toxicological  questions 
depending  on  the  test-tube  may  with  certainty  be 


applications  of  chemistry  to  the  art  of  healing. — 
Southern  Practitioner,  April,  1895. 


Attfield's  Chemistry.— New  (14th)  Edition.    Just  Ready. 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the 
Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the 
Science,  and  their  Application  to  Medicine  and  Pharmacy.  By  JOHN  ATTFIELD,  M.  A., 
Ph.  D.,  F.  I.  C.,  F.  K.  S.,  etc.,  Professor  of  Practical  Chemistry  to  the  Pharmaceutical 
Society  of  Great  Britain,  etc.  Fourteenth  edition,  specially  revised  by  the  Author 
for  America,  to  accord  with  the  new  U.  S.  Pharmacopoeia.  In  one  12mo.  volume  of  794 
pages,  with  88  illustrations.  Cloth,  $2.75;  leather,  $3.25. 
Attfield  is  the  most  widely  known  and  the  most  I  no  introduction.  It  occupies  a  unique  position. 


extensively  used  chemistry  that  has  ever  been 
published  in  the  English  language.  This  manual 
is  a  systematic  exponent  of  the  general  truths  of 
chemistry, and  is  written  mainly  for  pupils, assist- 
ants and  principals  engaged  in  medicine  and 
pharmacy.  It  will  be  found  equally  useful  as  a 
reading  book  for  students  having  no  opportunities 
of  attending  lectures  or  performing  experiments, 
or,  on  the  other  hand,  as  a  text-book  for  college 
pupils.  Attfield's  Chemistry  can  lay  claim  to  unex- 
ampled popularity. — Charlotte  Med.  Jour.,  Oct.,  1894. 
This  work  has  long  been  a  standard,  and  will  need 


no  introduction. 

for,  although  it  is  a  complete  manual  of  chemistry  | 
it  has  been  arranged  and  especially  adapted  to  the 
needs  of  the  physician  and  pharmacist.  The  work 
is  made  to  correspond  with  the  last  edition  of  the 
United  States  Pharmacopoeia.  The  present  edition 
contains  such  alterations  and  additions  as  seemed 
necessary  for  the  demonstration  of  the  latest 
developments  of  chemical  principles  and  the 
latest  applications  of  chemistry  to  pharmacy. 
The  fact  that  this  work  now  appears  in  its  four- 
teenth edition  is  abundant  proof  that  it  supplies 
a  distinct  want. —  Univ.  Med.  Magazine,  Dec.,  1894. 


Fownes'  Chemistry.— Twelfth  Edition. 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  By 
GEORGE  FOWNES,  Ph.  D.  Embodying  WATTS'  Physical  and  Inorganic  Chemistry.  New 
American,  from  the  twelfth  English  edition.  In  one  large  royal  12mo.  volume  of  1061 
pages,  with  168  engravings  and  a  colored  plate.  Cloth,  $2.75 ;  leather,  $3.25. 

Fownes'  Chemistry  has  been  a  standard  text- 
book upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 
everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.  It  has  steadily 
maintained  its  position  as  a  text-book  with  medi- 


cal students.  In  this  work  are  treated  fully :  Heat, 
Light  and  Electricity,  including  Magnetism.  The 
influence  exerted  by  these  forces  in  chemical 
action  upon  health  and  disease,  etc.,  is  of  the  most 
important  kind,  and  should  be  familiar  to  every 
medical  practitioner.  We  can  commend  the 
work  as  one  of  the  very  best  text-books  upon 
chemistry  extant. — Cincinnati  Med.  News. 


Bloxam's  Chemistry.— Fifth  Edition. 

Chemistry,  Inorganic  and  Organic.  By  CHARLES  L.  BLOXAM,  Profeseoi 
of  Chemistry  in  King's  College,  London.  New  American  from  the  fifth  London 
edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.  Cloth,  $2.00 ;  leather,  $3.00. 

complain  that  chemistry  is  a  hard  study.    Much 

attention  is  paid  to  experimental  illustrations  of 
chemical  principles  and  phenomena,  and  the 
mode  of  conducting  these  experiments.  The  book 


Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopte  the  most  direct  meth- 


ods in  stating  the  principles,  hypotheses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 
quence that  the  student  never  has  occasion  to 


maintains  the  position  it  has  always  held  as  one  of 
the  best  manuals  of  general  chemistry  In  the  Eng- 
lish language.— Detroit  Lancet. 


Luff's  Manual  of  Chemistry. 

A  Manual  of  Chemistry.  For  the  use  of  students  of  medicine.  By  ARTHUR 
P  LUFF  M  D  B.  So,,  Lecturer  on  Medical  Jurisprudence  and  Toxicological  Chemistry, 
St.  Mary's  Hospital  Medical  School,  London.  In  one  12mo.  vol.  of  622  pages,  with  36 
engravings.  Cloth,  $2.00.  See  Students'  Series  of  Manuals,  page  30. 

Greene's  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  By 
WILLIAM  H.  GREENE,  M.  D.,  Demonstrator  of  Chemistry  in  the  University  of  Pennsyl- 
vania. In  one  12mo.  volume  of  310  pages,  with  74  illus.  Cloth,  $1.75. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


10  Chemistry — (Continued),  Pharmacy. 

Caspari's  Pharmacy.— In  Press  for  Early  Issue. 

A  Text-Book  on  Pharmacy,  for  Students  and  Pharmacists.   By 

CHARLES  CASPARI,  JR  ,  Ph.  G.,  Professor  of  the  Theorv  and  Practice  of  Pharmacy  in  the 
Maryland  College  of  Pharmacy,  Joint  Editor  of  The  National  Dispensatory,  fifth  edition. 
In  one  very  handsome  octavo  volume,  richly  illustrated. 

The  author  is  widely  known  as  joint  editor  of  The  National  Dispensatory  (see  next  page) 
and  as  Professor  of  Pharmacy  in  one  of  the  foremost  pharmaceutical  colleges  in  America. 
He  is  therefore  exceptionally  qualified  to  prepare  a  work  of  the  highest  merit,  both  as  a 
text-book  for  students,  and  as  a  practical  reference  for  pharmacists  in  all  the  multifarious 
details  of  their  operations.  Modern  in  every  particular ;  convenient  in  size  through  avoid- 
ance of  obselete  and  unnecessary  matter,  richly  illustrated  and  issued  at  a  reasonable  price, 
Caspari's  Pharmacy  is  equally  assured  of  immediate  popularity  with  pharmacists  and  of 
adoption  as  the  standard  text-book  for  pharmaceutical  students. 

Vaucjlian  &  Novy  on  Ptomaines  and  Leucomaines.— New  Ed. 

Ptomaines,  Leucomaines  and  Bacterial  Proteids ;  or  the  Chemi- 
cal Factors  in  the  Causation  of  Disease.  By  VICTOR  C.  VATJGHAN,  Ph.  D., 
M.  D.,  Professor  of  Physiological  and  Pathological  Chemistry,  and  Associate  Professor  of 
Therapeutics  and  Materia  Medica  in  the  University  of  Michigan,  and  FREDERICK  G. 
NOVY,  M.  D.,  Instructor  in  Hygiene  and  Physiological  Chemistry  in  the  University  of 
Michigan.  New  (third)  edition.  In  one  12mo.  volume  of  about  400  pages.  In  press. 

A  notice  of  the  previous  issue  is  appended. 
This  book  is  one  that  is  of  the  greatest  import 
ance,  and  the  modern  physician  who  accepts 
bacterial  pathology  cannot  have  a  complete 
knowledge  of  this  subject  unless  he  has  carefully 
perused  it.  To  the  lexicologist  the  subject  is 
alike  of  great  import,  as  well  as  to  the  hygienist 


and  sanitarian.  It  contains  information  which 
is  not  easily  obtained  elsewhere,  and  which  is 
of  a  kind  that  no  medical  thinker  should  be 
without. — The  American  Journal  of  the  Medical 
Sciences. 


Remsen's  Theoretical  Chemistry.— Fourth  Edition. 

Principles  Of  Theoretical  Chemistry,  with  special  reference  to  the  Con- 
stitution of  Chemical  Compounds.  By  IRA  KEMSEN,  M.  D.,  Ph.  D.,  Professor  of  Chem- 
istry in  the  Johns  Hopkins  University,  Baltimore.  Fourth  and  thoroughly  revised  edi- 
tion. In  one  handsome  royal  12mo.  volume  of  325  pages.  Cloth,  $2.00. 

The  fourth  edition  of  Professor  Remsen's  well-  !  lation  into  German  and  Italian  speaks  for  its  ex- 
known  book  comes  again,  enlarged  and  revised,  alted  position  and  the  esteem  in  which  it  is  held 
Each  edition  has  enhanced  its  value.  Wemayeay  by  the  most  prominent  chemists.  We  claim  for 
without  hesitation  that  it  is  a  standard  work  on  this  little  work  a  leading  place  in  the  chemical 
the  theory  of  chemistry,  not  excelled  and  scarcely  literature  of  this  country. — The  American  Journal 
equalled  by  any  other  in  any  language.  Its  trans-  '.  of  the  Medical  Sciences. 

Charles'  Physiological  and  Pathological  Chemistry. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  A 
Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  By  T.  CRANSTOUN 
CHARLES,  M.  D.,  F.  R.  S.,  M.  S.,  formerly  Assistant  Professor  and  Demonstrator  of  Chem- 
istry and  Chemical  Physics,  Queen's  College,  Belfast.  In  one  handsome  octavo  volume 
of  463  pages,  with  38  woodcuts  and  1  colored  plate.  Cloth,  $3.50. 

Dr.  Charles  is  fully  impressed  with  the  impor-  I  nowadays.  Dr.  Charles  has  devoted  much  space 
tance  and  practical  reach  of  his  subject,  and  he  to  the  elucidation  ol  urinary  mysteries.  He  does 
has  treated  it  in  a  competent  and  instructive  man-  •  this  with  much  detail,  and  yet  in  a  practical  and 
ner.  We  cannot  recommend  a  better  book  than  j  intelligible  manner.  In  fact,  the  author  has  filled 
the  present.  In  fact,  it  fills  a  gap  in  medical  text-  |  his  book  with  many  practical  hints. — Medical  Rec- 
books,  and  that  is  a  thing  which  can  rarely  be  said  j  ord. 

Hoffmann  and  Powers'  Analysis. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medi- 
cinal Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their 
Identity  and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the 
use  of  Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceu- 
tical and  Medical  Students.  By  FREDERICK  HOFFMANN,  A.  M.,  Ph.  D.,  Public  Analyst  to 
the  State  of  New  York,  and  FREDERICK  B.  POWER,  Ph.  D.,  Professor  of  Analytical  Chem- 
istry in  the  Philadelphia  College  of  Pharmacy.  Third  edition,  entirely  rewritten  and 
much  enlarged.  In  one  octavo  volume  of  621  pages,  with  179  illustrations.  Cloth,  $4.25. 

Ralfe's  Clinical  Chemistry. 

Clinical  Chemistry.  By  CHARLES  H.  RALFE,  M.  D.,  F.  E.  C.  P.,  Assistant 
Physician  at  the  London  Hospital.  In  one  pocket-size  12mo.  volume  of  314  pages, 
with  16  illus.  Limp  cloth,  red  edges,  $1.50.  See  Students'  Series  of  Manuals,  page  30. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Pharmacy,  flateria  fledica,  Therapeutics.       11 

NEW  AND  THOROUGHLY  REVISED  EDITION. 

The  National  Dispensatory. 

Containing  the  Natural  History,  Chemistry,  Pharmacy,  Actions  and  Uses  of  Medi- 
cines^ including  those  recognized  in  the  Pharmacopoeias  of  the  United  States,  Great 
Britain  and  Germany,  with  numerous  references  to  the  French  Codex.  By  ALFRED 
STILLE,  M.  D.,  LL.  D.,  Professor  Emeritus  of  the  Theory  and  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  University  of  Pennsylvania,  JOHN  M.  MAISCH,  Phar.  D.,  late 
Professor  of  Materia  Medica  and  Botany  in  Philadelphia  College  of  Pharmacy,  Secretary 
to  the  American  Pharmaceutical  Association,  CHARLES  CASPARI,  JR.,  Ph.  G.,  Professor 
of  Pharmacy  in  the  Maryland  College  of  Pharmacy,  Baltimore,  and  HENRY  C.  C.  MAISCH, 
Ph.  G.,  Ph.  D.  New  (fifth)  edition,  thoroughly  revised  in  accordance  with  the  new  U.  8. 
Pharmacopoeia  (Seventh  Decennial  Revision,  1894).  In  one  magnificent  imperial  octavo 
volume  of  1910  pages,  with  320  engravings.  Cloth,  $7.25,  leather,  $8.00.  With  Keady 
Eeference  Thumb  letter  Index,  cloth,  $7.75 ;  leather,  $8.50. 

ON  the  first  appearance  of  The  National  Dispensatory  fifteen  years  ago  it  was  at  once 
recognized  by  the  pharmaceutical  and  medical  professions  as  satisfying  the  need 
for  a  work  affording  all  necessary  information  upon  its  subject,  with  authoritative 
accuracy,  and  with  a  completeness  and  convenience  attainable  only  by  the  exclusion  of 
obsolete  matter.  Its  success  in  filling  this  want  is  fully  attested  by  the  rapid  demand  for 
five  editions,  and  the  opportunity  thus  afforded  has  been  well  used  in  successive  revisions, 
each  placing  it  abreast  of  the  day  and  maintaining  the  characteristics  which  had  won  for 
it  a  leading  position. 

Of  all  its  issues  the  present  embodies  the  results  of  the  most  exhaustive  revision. 
The  sweeping  changes  in  the  new  United  States  Pharmacopoeia  are  thoroaghly  incorpor- 
ated, with  official  authorization  of  the  Committee  of  Revision,  and  full  use  has  been  made 
of  all  valuable  material  in  the  latest  issues  of  foreign  Pharmacopoeias.  The  volume  is 
accordingly  rich  in  pharmaceutical  and  chemical  information,  with  data,  formulas,  tables, 
etc.,  gathered  from  all  official  sources,  but  this  constitutes  only  a  single  department  of  its 
usefulness.  As  an  encyclopaedia  of  the  latest  and  best  therapeutical  knowledge  it  deals 
not  only  with  all  official  drugs,  but  also  with  all  the  new  synthetic  remedies  of  value 
and  with  the  unofficial  preparations  now  so  largely  in  use.  Pharmacists  will  appreciate 
its  systematic  descriptions  of  the  materia  medica,  its  clear  explanations  of  chemical  and 
pharmaceutical  processes  and  tests,  and  its  illustrations  of  important  drugs  and  of  the 
most  improved  apparatus.  Physicians  will  readily  perceive  the  indispensable  assistance 
offered  by  its  authoritative  statements  as  to  the  efficacy  of  drugs  in  the  light  of  the  most 
recent  medical  advances.  Arranged  alphabetically  in  the  text,  this  information .  is 
placed  most  suggestively  at  command  by  the  recommendations  grouped  under  the  various 
Diseases  in  the  Therapeutical  Index.  Together  with  the  General  Index  this  covers  more 
than  one  hundred  treble-columned  pages  containing  25,000  references.  The  immensity 
of  detail  comprised  in  this  single  volume  of  1900  pages  is  thus  most  forcibly  indicated. 
Though  the  present  edition  contains  far  more  matter  than  its  predecessor  it  is  maintained 
at  the  same  price  in  view  of  the  ever- increasing  demand.  Weights  and  Measures  are 
given  in  both  Ordinary  and  Metric  Systems. 

In  brief  the  new  edition  of  The  National  Dispensatory  is  presented  to  the  medical 
and  pharmaceutical  professions  as  the  equivalent  of  a  whole  library  of  pharmaceutical  and 
therapeutic  information ;  it  is  the  standard  of  accuracy,  the  embodiment  of  completeness 
without  inconvenient  bulk,  and  a  marvel  of  cheapness  owing  to  the  widespread  demand 
for  it  as  the  authority. 


The  careful  examination  of  this  large  volume 
will  strike  the  reader  with  surprise  at  the  great 
number  of  new  articles  added,  and  the  amount  of 
useful  and  accurate  information  regarding  their 
properties,  methods  of  preparation  and  therapeu- 
tical effects.  The  large  number  of  new  articles 
containing  all  the  latest  synthetic  remedies  and 
unofficial  remedies,  compass  the  entire  range  of 
available  information  in  the  line  of  the  work.  A 
number  of  very  complete  tables  together  with  all 
the  official  re-agents  and  solutions  for  qualitative 
and  quantitative  tests,  appear  in  the  appendix. 
Altogether  this  work  maintains  its  previous  high 
reputation  for  accuracy,  practical  uselulness  and 
encyclopaedic  scope,  and  is  indispensable  alike  to 
the  pharmacist  and  physician.  Every 
knows  of  it  and 

cian  properly  co 

all  doubtful  questions  regarding  the  properties, 


nd  uses  it,  and  almost  every  physi- 
consults  it  when  desirous  of  settling 


vised  with  equal  care  and  the  statements  of  the 
action  and  uses  have  been  arranged  not  only 
alphabetically  'under  the  various  drugs,  but  for 
practical  medical  usefulness  have  also  been  placed 
at  the  instant  command  of  those  seeking  infor- 
mation in  the  treatment  of  special  diseases  by 
being  arranged  under  the  various  diseases  in  a 
therapeutical  index.  The  readiness  with  which 
any  of  the  vast  amount  of  information  contained 
in  this  work  is  made  available  is  indicated  by  the 
twenty-five  thousand  references  in  the  two  in- 
dexes at  the  end  of  the  volume.— Boston  Medical 
and  Surgical  Journal. 

It  is  the  official  guide  for  the  medical  and  phar- 
maceutical professions.— Buffalo  Medical  and  Sur- 
gical Journal. 

The  book  is  recommended  most  highly  as  a 
book  of  reference  for  the  physician  and  is  invalu- 
able to  the  druggist  in  his  every-day  work.—  The 
Therapeutic  Gazette. 


preparation  and  uses  of  drugs.— Medical  Record.    _ 

The  descriptions  of  materia  medica  are  clear,  !     This  edition  of  the  Dispensatory  should  be  recojr- 
thorough  and  systematic,  as  are  also  the  explana-    nized  as  a  national  standard.— The  North  American 
tions  of  chemical  and  pharmaceutical  processes    Practitioner. 
and  tests.    The  therapeutical  portion  has  been  re- 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


12       Therapeutics,  flateria  fledica — (Continued). 


Hare's  Text-Book  of  Practical  Therapeutics.— Fourth  Edition. 

A  Text-Book  of  Practical  Therapeutics ;  With  Especial  Reference  to 
the  Application  of  Remedial  Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  By  HOBART  AMORY  HAKE,  M.  D.,  Professor  of  Therapeutics  and  Materia  Medica 
in  the  Jefferson  Medical  College  of  Philadelphia ;  Sec.  of  Convention  for  Revision  of  U.  S. 
Pharmacopoeia  of  1890.  With  special  chapters  by  DRS.  G.  E.  DE  SCHWEINITZ,  EDWARD 
MARTIN  and  BARTON  C.  HIRST.  New  (4th)  and  revised  edition.  In  one  octavo  volume 
of  740  pages.  Cloth,  $3.75 ;  leather,  $4.75. 

We  deem  the  portion  of  the  work  descriptive  of  i  practical  needs  of  every-day  medicine  corn- 
remedies  admirable  by  reason  of  the  clearness  j  mended  it  from  the  first  to  the  progressive  and 
and  conciseness  with  which  it  is  written.  The  working  therapeutist.  It  is  not  only  knowing 
descriptions  of  diseases,  though  exceedingly  what  to  give,  but  when  and  where  to  give,  and 
brief,  are  nevertheless  sufficiently  explicit  and  so  how  the  druse  will  act  in  given  conditions,  that 
expressed  as  to  render  the  work  a  very  practical  makes  one  a  scientific  practitioner  rather  than  an 
text-book,  and  also  one  which  will  serve  prac-  ignorant  empiric.  The  book  in  such  respects 
titioners  lor  ready  reference.  The  methods  of  supplies  every  need.  The  author  is  well  known 
treatment  are  at  once  sensible  and  practical.  The  as  a  progressive  therapeutist,  and  it  goes  without 
more  experienced  the  practitioner  who  turns  to  saying  that  all  the  new  or  valuable  drugs  receive 
this  book  for  reference,  the  more  sure  will  be  the  their  full  share  of  attention,  and  it  is  a  great  deal 
approval  of  the  methods  of  treatment  here  pro-  to  say  in  this,  as  with  other  features,  that  the  book 


posed. —  The  North  American  Practitioner,  Oct.,  '94. 
The  fact  that  the  fourth  edition  of  this  work  has 
appeared  within  four  years  attests  its  value  to  the 
general  practitioner,  and  its  appreciation  by  the 
medical  student.  Its  wide  application  to  the 


is  up-to-date  in  everything  pertaining  to  the  prac- 
tical therapeutical  needs  of  the  practitioner.  The 
work  has  also  been  revised  in  such  a  way  as  to 
make  it  uniform  with  the  United  States  Pharma- 
copceia. — Medical  Record,  October  20, 1894. 


A  System  of  Practical  Therapeutics 

BY  AHERICAN  AND  FOREIGN  AUTHORS. 
Edited    by   HOBART  AflORY   HARE,   fl.  D. 

Profettorof  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of  Philadelphia. 

In  a  series  of  contributions  by  seventy-eight  eminent  authorities.  In  three  large 
octavo  volumes  of  3544  pages,  with  434  illustrations.  Price,  per  volume  :  Cloth,  $5.00  ; 
leather,  $6.00  ;  half  Russia,  $7.00.  For  sale  by  subscription  only.  Address  the  Publishers. 
FuM  prospectus  free  to  any  address  on  application. 

The  various  divisions  have  been  elaborated  by  is  the  treatment  of  disease,  and  a  work  which  con- 
men  selected  in  view  of  their  special  fitness.  In  tributes  to  its  successful  management  is  to  be 
every  case  there  is  to  be  found  a  clear  and  concise  looked  upon  as  of  vast  use  to  humanity.  It  can- 
description  of  the  disease  under  consideration,  not  be  denied  that  therapeutic  resources,  whether 
corresponding  with  the  most  recent  and  well-  the  treatment  be  confined  to  the  mere  administra- 
established  views  of  the  subject.  In  treating  of  tion  of  drugs,  or  allowed  its  more  extended  appli- 
the  employment  of  remedies  and  therapeutical  cation  to  the  management  of  disease,  have  so 
measures,  the  writers  have  been  singularly  happy  greatly  multiplied  within  the  last  few  years  as  to 
in  giving  in  a  definite  way  the  exact  methods  em-  render  previous  treatises  of  little  value.  Herein 
ployed  and  the  results  obtained,  both  by  them-  will  be  found  the  great  value  of  flare's  encyelo- 
selves  and  others,  so  that  one  might  venture  with  pedic  work,  which  groups  together  within  a  single 
confidence  to  use  remedies  with  which  he  was  series  of  volumes  the  most  modern  methods 
previously  entirely  unfamiliar.  The  practitioner  known  in  the  management  of  disease.  We  can- 
could  hardly  desire  a  book  on  practical  thera-  not  commend  Hare's  System  of  Practical  Thera- 
peutics which  he  could  consult  with  more  interest  ptutics  too  highly;  it  stands  out  first  and  foremost 
and  profit.  —  The  North  American  Practitioner.  as  a  work  to  be  consulted  by  authors,  teachers, 

The  scope  of  this  work  is  beyond  that  of  any  and  physicians  throughout  the  world.  —  Buffalo 
previous  one  on  the  subject.  The  goal,  after  aM,  Medical  and  Surgical  Journal. 

Maiscli's  Materia  Medica.—  New  (6th)  Edition. 

A  Manual  of  Organic  Materia  Medica  ;  Being  a  Guide  to  Materia  Medica 
of  the  Vegetable  and  Animal  Kingdoms.  For  the  Use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  By  JOHN  M.  MAISCH,  Phar.  D.,  Prof,  of  Materia  Medica  and  Botany  in 
the  Philadelphia  College  of  Pharmacy.  New  (sixth)  edition,  thoroughly  revised.  In  one 
very  handsome  12mo.  volume  of  544  pages,  with  270  engravings.  Cloth,  $3.00. 

A  notice  of  the  previous  edition  is  appended. 
We    have    nothing   but    praise   for    Professor  |  of  Organic  Materia  Medica  as  one  of  the  best,  if  not 


Maisch's  work.    It  presents  no  weak  point,  even 
for  the  most  severe  critic.  The  book  fully  sustains  j 
the  wide  and  well-earned  reputation  of  its  popular  | 
author.    After  a  careful  perusal  of  the  book,  we 
do  not  hesitate  to  recommend  Maisch's  Manual  ' 


the  best  work  on  the  subject  thus  far  published. 
Its  usefulness  cannot  well  be  dispensed  with,  and 
students,  druggists,  pharmacists  and  physicians 
should  all  possess  a  copy  of  such  a  valuable 
book.  —  Medical  News. 


Edes'  Therapeutics  and  Materia  Medica. 

A  Text-Book  of  Therapeutics  and  Materia  Medica.  Intended  for  the 
Use  of  Students  and  Practitioners.  By  ROBERT  T.  EDES,  M.  D.,  Jackson  Professor  of 
Clinical  Medicine  in  Harvard  University.  Octavo,  544  pp.  Cloth,  $3.50 ;  leather,  $4.50. 


COHEN'S  HANDBOOK  OF  APPLIED  THERA- 
PEUT 1CS.  Being  a  Study  of  Principles  Applic- 
able and  an  Exposition  of  Methods  Employed 
in  the  Management  of  the  Sick.  By  SOLOMON 
SpLis-CoHES,  M  D.,  Professor  of  Clinical  Medi- 
cine and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic.  In  one  large  12mo.  volume, 


with  illnstrations.  Preparing. 
STILLE'S  THERAPEUTICS  AND  MATERIA 
MEDICA.  A  Systematic  Treatise  on  the  Action 
and  Uses  of  Medicinal  Agents,  including  their 
Description  and  History.  Fourth  edition,  re- 
vised and  enlarged.  In  two  octavo  volumes,  con- 
taining 1936  pages.  Cloth,$10.00 ;  leather, 512.00. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Practice  of  fledicine. 


13 


NEW    (SEVENTH)    EDITION. 

FLINT'S  PRACTICE  OF  MEDICINE 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed 
for  the  use  of  Students  and  Practitioners  of  Medicine.  By  AUSTIN  FLINT,  M.  D.,  LL.  D., 
Professor  of  the  Principles  and  Practice  of  Medicine  and  of  Clinical  Medicine  in  Belle- 
vue  Hospital  Medical  College,  N.  Y.  New  (7th)  edition,  thoroughly  revised  by  FRED- 
ERICK P.  HENRY,  M.  D.,  Professor  of  Principles  and  Practice  of  Medicine  in  the 
Woman's  Medical  College  of  Pennsylvania,  Philadelphia.  In  one  very  handsome  octavo 
volume  of  1143  pages,  with  illustrations.  Cloth,  $5.00;  leather,  $6.00. 


Its  peculiar  excellences  and  its  breadth  of  con- 
ception have  made  it  a  recognized  authority  from 
the  time  its  first  edition  appeared.  The  author 
was  a  born  teacher,  an  indefatigable  observer,  a 
painstaking  worker  and  a  thorough  medical  phi- 
losopher. His  clinical  pictures  of  diseases  are 
models  of  graphic  description,  minuteness  of 
detail  and  breadth  of  treatment  This  may  appear 
to  be  high  praise,  but  the  work  has  so  well  earned 
its  leading  place  in  medical  literature  that  but  one 
view  can  be  expressed  concerning  its  general 
character  as  a  text-book.  The  editor  has  done  his 
part  in  bringing  it  up  to  date,  not  only  in  refer- 
ence to  treatment  and  the  adaptation  of  the  newer 
remedies,  but  has  made  numerous  additions  in 
the  shapeof  the  newly  discovered  forms  of  disease, 


Among  the  large  number  of  new  books  upon  the 
practice  of  medicine  which  have  been  presented 
to  the  profession  within  the  last  few  years,  there 
is  none  which  will  stand  better  in  the  present  or 
in  the  future  than  the  seventh  edition  of  this 
book.  It  has  been  a  characteristic  of  Dr.  Flint's 
book  that  its  descriptions  of  clinical  cases  and  of 
the  practical  side  of  diseases  have  always  been 
wonderfully  true  to  life.  Further  than  this,  we 
think  the  profession  is  to  be  congratulated  that 
the  publishers,  in  obtaining  an  editor,  chose  one 
so  peculiarly  well  qualified  to  revise  and  bring  up 
to  date  those  articles,  in  connection  with  which 
the  greatest  progress  has  been  made  in  medical 
study,  for  Dr.  Henry  represents  at  once  that  side 
of  professional  life  which  appreciates  all  that  is 


and  has  elaborated  much  in  the  commoner  forms  good  and  at  the  same  time  is  not  so  optimistic  as 
which  the  recent  advances  have  made  necessary,  to  swallow  in  addition  much  that  is  bad.  We  be- 
The  element  of  treatment  is  by  no  means  ne-  lieve  that  the  profession,  the  teachers,  and  the 
glected;  in  fact,  by  the  editor  a  fresh  stimulus  is  j  students  of  the  country  will  appreciate  this  volume 

fiven  to  this  necessary  department  by  a  compre-  j  as  being  one  of  the  best  all-around  text-books 
ensive  study  of  all  the  new  and  leading  thera-    which  they  can  obtain. — Therapeutic  Gazette,  Oc- 
peutie  agents.— Medical  Record,  October  20, 1S94.      i  tober  15,  1894. 

Hartshorne's  Essentials  of  Practice.— Fifth  Edition. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Students  and  Practitioners.  By  HENRY  HARTSHORNE,  M.  D.,  LL.  D.,  lately  Professor 
of  Hygiene  in  the  University  of  Pennsylvania.  Fifth  edition,  thoroughly  revised  and 
rewritten.  In  one  12mo.  vol.  of  669  pages,  with  144  illus.  Cloth,  $2.75 ;  half  leather,  $3. 

Farquharson's  Therapeutics  and  Materia  Medica.— 4th  Ed. 

A  Guide  to  Therapeutics  and  Materia  Medica.  By  EGBERT  FAR- 
qtJHARSON,  M.  D.,  F.  B.  C.  P.,  LL.  D.,  Lecturer  on  Materia  Medica  at  St.  Mary's  Hospi- 
tal Medical  School,  London.  Fourth  American,  from  the  fourth  English  edition. 
Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia.  By  FRANK  WOODBURY,  M.  D.,  Pro- 
fessor of  Materia  Medica  and  .Therapeutics  and  Clinical  Medicine  in  the  Medico-Chi- 
rurgical  College  of  Philadelphia.  In  one  handsome  12mo.  vol.  of  581  pp.  Cloth,  $2.50. 
It  may  correctly  be  regarded  as  the  most  modern  j  copoeias,  as  well  as  considering  all  non-official  but 
work  of  its  kind.  It  is  concise,  yet  complete,  important  new  drugs,  it  becomes  in  fact  a  miniature 
Containing  an  account  of  all  remedies  that  have  dispensatory. — Pacific  Medical  Journal. 
a  place  in  the  British  and  United  States  Pharma- 

Bruce's  Materia  Medica  and  Therapeutics.— Fifth  Edition. 

Materia  Medica  and  Therapeutics.  An  Introduction  to  Rational  Treat- 
ment. By  J.  MITCHELL  BRUCE,  M.  D.,  F.  E.  C.  P.,  Physician  and  Lecturer  on  Materia 
Medica  and  Therapeutics  at  Charing-Cross  Hospital,  London.  Fifth  edition.  In  one 
12mo.  volume  of  591  pages.  Cloth.  $1.50.  See  Stiulents'  Series  of  Manuals,  page  30. 

The  pharmacology  and  therapeutics  of  each  drug 
are  given  with  great  fulness,  and  the  indications  for 
its  rational  employment  in  the  practical  treatment 
of  disease  are  pointed  out.  The  Materia  Medica 
proper  contains  all  that  is  necessary  for  a  medical 
student  to  know  at  the  present  day.  The  third 


part  of  the  book  contains  an  outline  of  general 
therapeutics,  each  of  the  symptoms  of  the  body 
being  taken  in  turn,  and  the  methods  of  treat- 
ment illustrated.  A  lengthy  notice  of  a  book  so  well 
known  is  unnecessary. — Med.  Chronicle. 


FLINT'S  PRACTICAL  TREATISE  ON  THE 
DIAGNOSIS,  PATHOLOGY  AND  TREATMENT 
OF  DISEASES  OF  THE  HEART.  Second  re- 
vised and  enlarged  edition.  In  one  octavo  vol- 
ume of  550  pages,  with  a  plate.  Cloth,  $4. 

FLINT  ON  PHTHISIS     In  one  octavo  volume 

FUNrSPa|stAYCS10OhN  *Co1isER  VATIVE  MEDI- 
CINE  AND  KINDRED  TOPICS.  In  one  very 
handsome  royal  12mo.  volume  of  210  pages. 

LYONS''  TREATISE  ON  FEVER.     In  one  8vo. 
Cloth,  $2.25 

THE  STUDY   OF 


vohime  of  354  pages.    Cloth, 
HUDSON'S    LECTURES   ON 


FEVER.    In  one  octavo  volume  of  308  pages. 

LA  ROCHE  ON  YELLOW  FEVER,  in  its  Histori- 
cal, Pathological,  Etiological  and  Therapeutical 
Relations.  Two  octavo  vols.,146«  pp.  01oth.S7.00. 

BRUNTON'S  PHARMACOLOGY,  THERAPEU- 
TICS AND  MATERIA  MEDICA.  Octavo,  1305 
pages,  230  illustrations. 

HERMANN'S  EXPERIMENTAL  PHARMACOL- 
OGY. A  Handbook  of  Methods  for  Determining 
the  Physiological  Action  of  Drugs.  Translated, 
with  the  Author's  permission,  and  with  exten- 
sive additions,  by  R.  M.  SMITH,  M.  D.  12mo., 
199  pages,  with  32  illustrations.  Cloth,  $1.60. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


14  Prac.  of  fledicine,  Treatment,  Digestive  Syst. 
Lyman's  Practice  of  Medicine. 

The  Principles  and  Practice  of  Medicine.  For  the  Use  of  Medical 
Students  and  Practitioners.  By  HENRY  M.  LYMAN,  M.  D.,  Professor  of  the  Principles 
and  Practice  of  Medicine,  Rush  Medical  College,  Chicago.  In  one  very  handsome  octavo 
volume  of  925  pages,  with  170  illustrations.  Cloth,  $4.75 ;  leather,  $5.75. 


Professor  Lyman's  valued  and  extensive  expe- 
rience here  reduced  in  text-book  form,  is  indeed 
very  valuable  both  to  college  students  and  physi- 
cians. In  this  work  we  have  an  excellent  tieatise 
on  the  practice  of  medicine,  written  by  one  who 


ascertain  in  a  short  time  all  the  necessary  facts 
concerning  the  pathology  or  treatment  of  any  dis- 
ease will  find  here  a  safe  and  convenient  guide. — 
The  Charlotte  Medital  Journal. 
The  reader  of  the  above  volume  will  be  at  once 


is  not  only  familiar  with  his  subject,  but  who  has  }  struck  with  its  excellence.    Its  contents  are  corn- 
also  learned  through  practical  experience  in  teach-  |  plete  and  concise,  it  is  fully  abreast  with  the  times, 


ing  what  are  the  needs  of  the  student  and  how 
to  present  the  facts  to  his  mind  in  the  most  readily 
assimilable  form.  Each  subject  is  taken  up  in 
order,  treated  clearly  but  briefly,  and  dismissed 
when  all  has  been  said  that  need  be  said  in  order 
to  give  the  reader  a  clear-cut  picture  of  the  dis- 
ease under  discussion.  The  reader  is  not  con- 
fused by  having  presented  to  him  a  variety  of 
different  methoos  of  treatment,  among  which  he 
is  left  to  choose  the  one  most  easy  of  execution, 
but  the  author  describes  the  one  which  is,  in  his 
judgment,  the  best.  This  is  as  it  should  be.  The 
student  and  even  the  practitioner,  should  be 
taught  the  most  approved  method  of  treatment. 
The  practical  and  busy  physician,  who  wants  to 


and  is  such  a  book  as  is  needed  by  students  and 
practitioners.  The  average  doctor  has  neither  the 
time  nor  the  patience  to  read  through  the  pages 
of  an  encyclopedia  to  gain  the  points  he  desires. 
This  Practice  will  give  him  all  the  necessary  in- 
formation in  a  form  easily  grasped.  The  parts  of 
chapters  relating  to  differential  diagnosis  leave 
nothing  to  be  desired;  they  show  the  author's 
familiarity  with  his  subjects,  and  his  methods  as 
a  t»acher.  Evidently  the  points  are  not  culled 
from  other  volumes;  they  bear  the  stamp  of 
originality.  In  a  word,  the  volume  is  up  to  date, 
is  readable  and  instructive,  and  is  far  superior  to 
the  majority  of  books  of  the  kind. —  University 
Medical  Magazine. 


The  Tear-Book  of  Treatment  for  1895.    Just  Ready. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine and  Surgery.     In  one  12mo.  vol.  of  495  pages.    Cloth,  $1.50. 

***  For  special  commutations  with  periodicals  see  pages  1  and  2. 

It  would  be  difficult  indeed  to  imagine  a  book  practitioner  needs.  He  can  find  anything  pertain- 
more  nearly  suited  to  the  every-day  needs  of  the  ing  to  any  subject  in  a  moment's  time,  and  he  may 
medical  practitioner  or  writer  than  this.  The  con-  rest  assured  that  it  is  the  most  modern  and  reliable 
tributorstothis  volume  are  among  the  most  promi-  view  now  accepted.  It,  year  by  year,  keeps  him 
nent  and  well-known  writers  and  teachers  of  the  apprised  of  important  advances  in  all  branches 
day,  and  their  articles  and  opinions  will  be  appre-  of  medicine,  and  presents  them  in  a  well-con- 


elated  by  all  who  are  fortunate  and  wise  enough 
to  secure  them.     It  is  the  very  book  the  busy 


densed  and  classified  form. — The  Charlotte  Med- 
ical Journal,  May,  1895. 


The  Tear-Books  of  Treatment  for  1891,  1892,  and  1893. 

12mos.,  485  pages.     Cloth,  $1.50  each. 


The  Tear-Books  of  Treatment  for  1886  and  1887. 

Similar  to  above.     12mos.,  320-341  pages.    Cloth,  $1.25  each. 

Habershon  on  the  Abdomen. 

On  the  Diseases  of  the  Abdomen ;  Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  (Esophagus,  Csecum,  Intestines  and  Peritoneum.  By 
S.  O.  HABERSHOX,  M.  D.,  Senior  Physician  to  and  late  Lecturer  on  Principles  and  Prac- 
tice of  Medicine  at  Guy's  Hospital,  London.  Second  American  from  third  enlarged  and 
revised  English  edition.  In  one  handsome  octavo  vol.  of  554  pages,  with  illus.  Cloth,  $3.50. 


This  valuable  treatise  on  diseases  of  the  stomach 
and  abdomen  will  be  found  a  cyclopaedia  of  infor- 
mation, systematically  arranged,  on  all  diseases  of 
the  alimentary  tract,  from  the  mouth  to  the 


rectum.  A  fair  proportion  of  each  chapter  Is 
devoted  to  symptoms, pathology,  and  therapeutics. 
— New  York  Medical  Journal. 


TANNER'S  MANUAL  OF  CLINICAL  MEDICINE 
AND  PHYSICAL  DIAGNOSIS.  Third  American 
from  the  second  London  edition.  Revised  an«i 
enlarged  by  TILBUBY  Fox,  M.  D.  In  one  12mo. 
volume  of  362  pp.  with  illus.  Cloth,  81.50. 

DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES.  By  N.  8  DAVIS, 
M.  D.  Edited  by  FRANK  H.  DAVIB,  M.  D.  Second 
edition.  12mo.  287  pages.  Cloth,  81.71 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion. In  1  vol.  8vo.,  416  pp.  Cloth,  $3.00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  8vo.,  pp.  493.  Cloth,  J3.50. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
S20  pages.  Cloth.  82.50. 

FLINT'S  PRACTICAL  TREATISE  ON  THE 
PHYSICAL  EXPLORATION  OF  THE  CHEST 
AND  THE  DIAGNOSIS  OF  DISEASES  AF- 
FECTING THE  RESPIRATORY  ORGANS. 
Second  and  revised  edition.  In  one  handsome 
octavo  volume  of  591  pages.  Cloth,  84.50. 

STURGE8'    INTRODUCTION  TO  THE  STUDY  j 


OF  CLINICAL  MEDICINE.  Being  a  Guide  to 
the  Investigation  of  Disease.  In  one  handsome 
I2mo.  volume  of  127  pages.  Cloth,  81.25. 

REYNOLDS'  SYSTEM  OF  MEDICINE.  With 
notes  and  additions  by  HENRY  HARTSHORNE,  A.M., 
M.  D.  Three  octavo  volumes,  containing  3056 
double-columned  pages,  with  317  illustrations. 
Price  per  volume,  cloth,  $5.00;  sheep, 86.00;  half 
Russia,  SG.50.  Subicription  only. 

WATSON'S  LECTURES  ON  THE  PRINCIPLES 
AND  PRACTICE  OF  PHYSIC.  Edited  with 
additions,  and  190  illustrations,  by  HENKT  HABTS- 
HOBNE,  A.  M.,  M.  D.  In  two  large  octavo  volumes 
of  1840  pages.  Cloth,  39.00;  leather,  811.00. 

PEPPER'S  SYSTEM  OF  PRACTICAL  MEDI- 
CINE BY  AMERICAN  AUTHORS.  Edited  by 
WILLIAM  PEPPER,  M.  D.,  LL.  D.,  Provost  and 
Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  Univer- 
sity of  Pennsylvania.  The  complete  work,  in 
five  volumes,  contains  5573  pages,  with  198  illus- 
trations. Price,  per  volume,  cloth,  $5;  leather, 
§6;  half  Russia,  87.  Subscription  only. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Practice  of  fledicine,  Diagnosis,  Heart.         15 


Musser's  Medical  Diagnosis. 

A  Practical  Treatise  on  Medical  Diagnosis  For  the  Use  of  Students 
and  Practitioners.  By  JOHN  H.  MUSSER,  M.  D.,  Assistant  Professor  of  Clinical  Medicine, 
University  of  Pennsylvania,  Philadelphia.  Tn  one  very  handsome  octavo  volume  of  873 
pages,  with  162  illustrations  and  2  colored  plates.  Cloth,  $5;  leather,  $6. 


The  aim  of  the  author  has  been  to  make 
the  work  eminently  practical.  Dr.  Musser 
has  succeeded  in  bringing  together  a  large  and 
valuable  collection  of  clinical  data  drawn  from  his 
own  extended  experience  and  from  exhaustive 
literary  research,  and  has  presented  them  in  an 
unusually  clear  and  concise  manner.  In  brief, 
the  book  is  thoroughly  modern,  readable  and  in- 
structive, and,  we  believe,  superior  to  any  work  of 
the  kind  before  the  profession. —  University  Medical 
Magazine. 

Modern  methods  of  medical  teaching  and  study 
have  rendered  treatises  like  the  present  an  abso- 
lute necessity.  The  present  work  is  to  be  com- 
mended alike  for  its  logical  arrangement,  accurate 
observation  and  clearness  of  expression.  The 
chapter  on  bacteriology  is  especially  commenda- 
ble, because  it  contains  everything  practically 
necessary  for  clinical  work. — Medical  Record. 

The  book  should  receive  a  hearty  reception  from 
students  and  medical  men ;  it  contains  much  in- 


formation essential  to  good,  scientific  medical 
work.  It  is  with  pleasure  that  we  can  state  that 
the  work  has  been  adopted  as  a  text-book  at  the 
Johns  Hopkins  Medical  School  and  Harvard  Uni- 
versity, and  that  it  has  met  with  marked  approval 
in  other  teaching  centres. — International  Medical 
Magazine. 

The  whole  book  impresses  one  as  being  the 
concentration  of  a  very  thorough  knowledge  of 
all  the  fact?  resorted  to  in  the  making  of  a  careful 
diagnosis  by  means  of  modern  methods.  Dr. 
Musser's  book  will  at  once  take  a  prominent  and 
permanent  position  among  the  text-books  of  the 
medical  schools  of  the  country,  and  we  recom- 
mend it  most  highly  to  those  practitioners  who 
wish  not  only  to  get  the  views  or  the  general  pro- 
fession in  regard  to  important  points  of  diagnosis, 
but  who  also  desire  a  work  in  which  the  author 
expresses  his  own  opinions,  based  upon  careful 
observation  and  wide  experience. —  The  Thera- 
peutic Gazette. 


Flint  on  Auscultation  and  Percussion.— Fifth  Edition. 

A  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis 
of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  By  AUSTIN  FLINT,  M.  D., 
LL.  D.,  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Medi- 
cal College,  New  York.  Fifth  edition.  Edited  by  James  C.  Wilson,  M.  D.,  Lecturer 
on  Physical  Diagnosis  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  hand- 
some royal  12mo.  volume  of  274  pages,  with  12  illustrations. 

Whitla's  Dictionary  of  Treatment. 

A  Dictionary  of  Treatment ;    or  Therapeutic  Index,  including 
Medical  and  Surgical  Therapeutics.     By  WILLIAM  WHITLA,  M.  D.,  Professor 
of  Materia  Medica  and  Therapeutics  in  the  Queen's  College,  Belfast.  Revised  and  adapted 
to  the  United  States  Pharmacopoeia.     In  one  square,  octavo  vol.  of  917  pp.     Cloth,  $4.00. 
We  have  already  dictionaries  of  medicine  and    the  younger  practitioner  will  find  in  it  exactly  the 
dictionaries  of  surgery;  Dr.  Whitla  now  provides  !  help  he  so  often  needs  in  the  treatment  both  < 
us  with  a  dictionaryof  treatment.    And  reference  ,  those  who  are  ill,  and  those  who  are  ailing.  At  t 
to  the  volume  shows   that  it   really   is  what   it  |  same  time  the  most  experienced  members  of  t 

•    ••--     -'    ----"     profession  may  usefully  consult  its  pages  for  the 


professes  to  be.  The  several  diseased  condi- 
tions are  arranged  in  alphabetical  order,  and 
the  methods— medical,  surgical,  dietetic,  and 
climatic— by  which  they  may  be  met,  considered. 
On  every  page  we  find  clear  and  detailed  direc- 
tions for  treatment  supported  by  the  author's 
personal  authority  and  experience  whilst  the 
recommendations  of  other  competent  observers 
are  also  critically  examined.  Tne  book  abounds 
with  useful,  practical  hints  and  suggestions,  and 


purpose  of  learning  what  is  really  trustworthy  in 
the  later  therapeutic  developments.  The  Diction- 
ary is,  in  short,  the  recorded  experience  of  a  prac- 
tical scientific  therapeutist,  who  has  carefully 
studied  diseases  and  disorders  at  the  bed-side  and 
in  the  consulting-room,  and  has  earnestly  ad- 
dressed himself  to  the  cure  and  relief  of  his 
patients. — The  Glasgow  MedicalJownal. 


Taylor's  Index  of  Medicine.— Just  Ready. 

An  Index  of  Medicine.  By  SEYMOUR  TAYLOR,  M.  D.,  M.  R.  C.  P.,  Assistant 
Physician  to  the  West  London  Hospital.  In  one  12mo.  vol.  of  802  pages.  Cloth,  $3.75. 

The  author  has  prepared  a  work  of  great  value  systems  of  the  body  are  considered  and  the 
alike  to  physicians  and  students.  The  volume  is  ;  cause,  symptoms,  pathology,  treatment  and 
a  concise  "Practice  of  Medicine,"  the  diseases  !  prognosis  of  each  affection  are  succinctly  stated, 
beine  grouped  systematically  in 'order  to  secure  ,  Numerous  illustrations  together  with  tabulations 
for  tne  reader  the  many  advantages  resulting  of  differential  diagnosis,  tests,  etc.,  elucidate  the 
from  rationaf  arrangement.  After  valuable  chap-  ;  text  and  condense  a  great  amount  of  necessary 
£r™oT"  Disease," "General  Pathology,"  "Gen- ,  knowledge  in  the  clearest  manner  The  work  is 
eral  Diseases "  "  Specific  Infectious  Diseases"  one  which  merits  and  will  doubtless  obtain  a 
and  "Specific'  Fevers,"  the  various  organs  and  wide  popularity.-TVisSf.  Louts  dmupu,  May.  1895. 

Fothergill's  Handbook  of  Treatment.— Third  Edition. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of 
Therapeutics.  By  J.  MILKER  FOTHERGILL,  M.D.,  Edin.,  M ..R C  .P.,  Lond  ,  Physician 
to  the  CUy^f  London  Hospital  for  Diseases  of  the  Chest.  Third  edition.  In  one  8vo. 
volume  of  661  pages.  Cloth,  $3.75 ;  leather,  $4.75. 

Thi9        a  wonderful  book     If  there  be  such  a  I  together  in  a  single  chapter,  and  the  relations 

thta  as  "medfdne  made  easy,'; "his  is  the  work  to    between  the  twoclearly  stated  cannot  fa  1  to  prove 

pnnmnli^  this  result  -Virqinia  Medical  Monthly,    a  great  convenience  to  many  thoughtful  but  busy 

BROADBENT  ON  THE  PULSE.    In  one  12mo.  volume  of  312  pages.    Cloth,  $1.76.    See  Seriet  of 
Clinictl  Manuals,  page  30. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


16   Practice,  Electricity,  Cholera,  Food,  Hygiene. 
Hayem's  Physical  and  Natural  Therapeutics.— Shortly. 

.  Physical  and  Natural  Therapeutics.  The  Remedial  Use  of  Heat, 
Electricity,  Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral  Waters.  By 
GEORGES  HAYEM,  Professor  of  Clinical  Medicine  in  the  Faculty  of  Medicine  of  Paris. 
Edited  with  the  assent  of  the  A.uthor  by  HOBART  AMORY  HARE,  M.  D.,  Professor  of 
Therapeutics  in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  handsome  octavo 
volume  with  numerous  illustrations. 

The  merited  and  increasing  importance  of  non-medicinal  therapeutics  makes  this  volume 
one  of  timely  interest,  and  the  eminent  standing  of  author  and  editor  will  ensure  for  it  a 
position  of  undisputed  authority  and  value. 

Herrick's  Diagnosis.— Shortly. 

A  Handbook  of  Diagnosis.  By  JAMES  B  HERRICK,  M.D.,  Adjunct 
Prof,  of  Medicine,  Bush  Medical  Coll.,  Chicago.  In  one  12mo.  vol.  of  about  400  pages. 

Yeo's  Medical  Treatment. 

A  Manual  of  Medical  Treatment  or  Clinical  Therapeutics.  By 
1.  BURNEY  YEO,  M.  D.,  F.  R.  (  A  P.,  Prof,  of  Clinical  Therapeutics  in  King's  Coll.,  London. 
In  two  12mo.  volumes  containing  1275  pages,  with  illustrations.  Cloth,  $5.50. 

In  Dr.  Yeo's  book  the  study  of  the  treatment  of  given  with  regard  to  diet,  mode  of  life,  and  gen- 
disease  is  approached,  not  from  the  side  of  the  eral  treatment,  which  are  often  as  important  as  the 
drug  or  remedy  as  in  works  on  therapeutics,  but  treatment  by  drugs. — Med.  Chronicle,  January,  1894. 
"from  the  side  of  the  disease."  The  various  dis-  The  discussion  of  the  different  ailments  has  a 
eases  are  grouped  together,  a  short  account  is  given  distinctly  practical  turn  toward  the  main  purpose 
of  the  clinical  history,  course  and  pathology  of  of  the  book.  Standard  formulae  are  introduced 
each,  and  from  a  consideration  thereof,  indications  from  eminent  practitioners,  and  all  the  drugs  of 
for  treatment  are  arrived  at;  then  follows  a  full  dis-  ;  recognized  value  are  grouped  in  the  order  of  their 
cussion  of  the  best  methods  of  carrying  out  these  importance.  The  dosage  receives  careful  atten- 
indications.  Each  section  contains  a  number  of  tion,  which  is  a  feature  that  cannot  be  too  highly 
prescriptions  which  the  author  has  found  most ;  commended.  It  cannot  fail  to  be  an  exceedingly 
useful,  and  at  the  end  of  every  chapter  is  added  a  j  useful,  suggestive  and  instructive  work  to  the 
selection  of  formulae  from  the  writings  of  various  physician  who  wishes  to  be  well  up  in  the  present 
well-known  physicians.  The  work  is  exceedingly  advanced  and  scientific  therapeutics  of  the  day. — 
practical,  and  the  details  of  the  various  methods  j  Medical  Record. 
of  treatment  are  always  given.  Full  directions  are  I 

Yeo  on  Food  in  Health  and  Disease. 

Food  in  Health  and  Disease.  By  I.  BURNEY  YEO,  M.D.,  F.E.C.  P., 
Professor  of  Clinical  Therapeutics  in  King's  College,  London.  In  one  12mo.  volume  of 
590  pages.  Cloth,  $2.00.  See  Series  of  Clinical  Manuals,  page  30. 

Dr. Yeo  supplies  in  a  compact  form  nearly  all  that 
the  practitioner  requires  to  know  on  the  subject  of 
diet.  The  work  is  divided  into  two  parts — food  in 
health  and  food  in  disease.  Dr.  Yeo  has  gathered 
together  from  all  quarters  an  immense  amount  of 
useful  information  within  a  comparatively  small 


compass,  and  he  has  arranged  and  digested  his 
materials  with  skill  for  the  use  of  the  practitioner. 
We  have  seldom  seen  a  book  which  more  thor- 
oughly realizes  the  object  for  which  it  was  written 
than  this  little  work  of  Dr.  Yeo. — British  Medical 
Journal. 


Bartholow  on  Cholera. 

Cholera :  Its  Causes,  Symptoms,  Pathology  and  Treatment.  By 
ROBERTS  BARTHOLOW,  M.  D.,  LL.  D.,  Emeritus  Professor  of  Materia  Medica,  General 
Therapeutics  and  Hygiene  in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  12mo. 
volume  of  127  pages,  with  9  illustrations.  Cloth,  $1.25. 

The  author  has  sought  to  make  a  practical  book    and  the  latest  therapeutical  methods  in  vogue  in 

India,  Europe  and  America  The  volume  is  writ- 
ten in  the  author's  usual  pleasant  style,  and  will 
satisfy  the  desire  of  any  one  that  wishes  to  obtain 
the  most  recent  information  on  the  subject. — The 


New  York  Medical  Journal. 


in  the  smallest  compass.  The  symptoms  and 
pathology  of  the  disease  are  described  separ- 
ately ia  a  brief  and  comprehensive  manner.  The 
final  chapter,  on  the  treatment  of  cholera,  gives 
the  prophylactic  measures,  including  quarantine 

Richardson's  Preventive  Medicine. 

Preventive  Medicine.    By  B.  W.  RICHARDSON,  M.  D.,  LL.  D.,  F.  R.  S.,  Fel- 
low of  the  Royal  Coll.  of  Phys.,  London.   In  one  8vo.  vol.  ot  729  pp.   Cloth,  $4;  leather,  $5. 
There  is  perhaps  no  similar  work  written  for    scholarly ;  the  discussion  of  the  question  of  disease 


the  general  public  that  contains  such  a  complete, 
reliable  and  instructive  collection  of  data  upon 
the  diseases  common  to  the  race,  their  origins, 
causes,  and  the  measures  for  their  prevention. 
The  descriptions  of  diseases  are  clear,  chaste  and 


BARTHOLOW'S  PRACTICAL  TREATISE  ON 
THE  APPLICATIONS  OF  ELECTRICITY  TO 
MEDICINE  AND  SURGERY.  By  ROBERTS 
BARTHOLOW,  A.M.,  M.D.,  LL.D.,  Emeritus  Pro- 
fessor of  Materia  Medica  and  General  Thera- 
peutics in  the  Jefferson  Med.  Coll.  of  Philadel- 
phia, etc.  Third  edition.  In  one  octavo  volume 
of  308  pages,  with  110  illustrations. 

PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  pages.  Cloth,  82.00. 


is  comprehensive,  masterly  and  fully  abreast  with 
the  latest  and  best  knowledge  on  the  subject,  and 
the  preventive  measures  advised  are  accurate, 
explicit  and  reliable. — The  American  Journal  of  the 
Medical  Sciences. 


SCHREIBER'S  MANUAL  OF  TREATMENT  BY 
MASSAGE  AND  METHODICAL  MUSCLE  EX- 
ERCISE. Translated  by  WALTER  MENDELSON, 
M.D.,  of  New  York.  In  one  8vo.  volume  of  274 
pp.,  with  117  engravings. 

CHAMBERS'  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.  Cloth,  82.75. 

STILLE  ON  CHOLERA:  Its  Origin,  History, 
Causation,  Symptoms,  Lesions,  Prevention  and 
Treatment.  In  one  handsome  12mo.  volume  of 
163  pages,  with  a  chart.  Cloth,  §1.25. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Throat,  Nose,  Lungs,  flind,  Nerves. 


17 


Seller  on  the  Throat  and  Nose.— Fourth  Edition. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the 
Throat,  Nose  and  Naso-Pharynx.  By  CARL  SEILER,  M.D.,  Lecturer  on 
Laryngoscopy  in  the  University  of  Pennsylvania.  Fourth  edition.  In  one  handsome 
12mo.  volume  of  414  pages,  with  107  illustrations  and  2  colored  plates.  Cloth,  $2.25. 


This  little  book  is  eminently  practical,  and  will 
prove  of  interest  not  only  to  the  specialist,  but  to 
the  general  practitioner  as  well.  It  deals  with  the 
subject  in  a  clear  and  distinct  manner,  and  the 
text  is  copiously  illustrated  with  diagrams  and 
colored  plates.  So  little  attention  is  paid  ordi- 
narily to  the  examination  of  the  larynx  that  the 
need  of  such  a  book  has  long  been  felt.  By  con- 
sulting its  pages  anyone  can  learn  the  necessary 
manipulations,  and,  by  a  little  practice,  soon  be- 


come expeit  in  the  use  of  the  laryngeal  mirror,  a 
method  of  examination  too  often  neglected.  The 
anatomy  of  the  larynx  is  explained  with  especial 
care,  and  the  operative  procedures  for  various 
diseases  of  the  throat,  tonsils,  etc.,  are  carefully 
explained.  Approved  methods  of  treatment  are 
dealt  with  in  a  very  satisfactory  way,  and  all  the 
most  useful  remedial  agents  are  described.— 
International  Medical  Magazine. 


Browne  on  the  Throat  and  Nose.— Fourth  Edition. 

The  Throat  and  Nose  and  Their  Diseases.  By  LENNOX  BROWNE, 
F.  K.  C.  S.,  E.,  Senior  Physician  to  the  Central  London  Throat  and  Ear  Hospital. 
Fourth  and  enlarged  edition.  In  one  imperial  octavo  volume  of  751  pages,  with  1 20 
illustrations  in  color,  and  235  engravings  on  wood.  Cloth,  $6.50. 


The  subject  is  here  exhaustively  treated  on 
lines  of  thorough  acquaintance  with  the  anatomy, 
the  physiology  and  physics  of  the  organs  involved 
and  the  pathology  of  the  disease  to  which  they 
are  subject.  To  the  author  we  have  awarded  the 
credit  of  having  added  to  a  thorough  understand- 
ing of  the  di;- eases  with  which  he  deals  the  choice 
of  the  best  treatment  afforded  by  the  present  state 


of  knowledge. —  TheAmer.  Practitioner  and  A'eirg. 

Although  quite  complete  enough  for  the  use  of 
specialists,  it  is  at  the  same  time  so  clear  as  to  be 
of  daily  value  to  the  general  practitioner,  who  will 
find  at  the  end  of  the  volume  a  number  of  well- 
tried  formulas  most  in  vogue  at  the  London  hos- 
pitals for  diseases  of  the  throat—  The  Canada 
Medical  Record. 


Mackenzie  on  the  Nose  and  Throat.— Preparing. 

The  Diseases  of  the  Nose  and  Throat.  By  JOHN  NOLAND  MACKEN- 
ZIE, M.  D.,  Lecturer  on  Laryngology  in  the  Medical  School  of  the  Johns  Hopkins  Uni- 
versity, Clinical  Professor  of  Diseases  of  the  Throat  and  Nose  _ in  the  University  of 
Maryland,  Baltimore.  In  one  octavo  volume  of  abnut  600  pages,  richly  illustrated. 

Tuke  on  the  Influence  of  the  Mind  on  the  Body. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in 
Health  and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  By 
DANIEL  HACK  TUKE,  M.  D.,  Joint  Author  of  the  Manual  of  Psychological  Medicine, 
etc.  New  edition.  Thoroughly  revised  and  rewritten.  In  one  8vo.  volume  of  467  pages, 
with  2  colored  plates.  Cloth,  $3  00. 

It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 


amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomena  the  more  firmly 
has  he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  most  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 


commend 'itself  to  every  thoughtful  understand- 
ing.— New  York  Medical  Journal. 


Clouston  on  Mental  Diseases. 

Clinical  Lectures  on  Mental  Diseases.  By  THOMAS  S.  CLOOSTON, 
M  D  Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh.  With  an  Appen- 
dix containing  an  Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several 
States  and  Territories  relating  to  the  Custody  of  the  Insane.  By  CHARLES  F.  FOLSOM, 
M  D  Ass't  Professor  of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  octavo 
volume  of  541  pages,  with  eight  lithographic  plates,  four  of  which  are  colored  Cloth  $4. 
Folsom's  Abstract  also  separate,  in  one  8vo.  vol.  of  108  pages.  Cloth,  |>  1.50. 
of  the  diseases  and  cases  are  and  descriptions  given  as  to  the 


commends  it  highly,  and  mi»«»«  »=  "«•  »-  -~  --r"," 
in  anyother  work  on  mental  diseases,  is  the  hints 

Playf air  on  Nerve  Prostration  and  Hysteria. 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria. 
By  W.  S.  PlxYFAiR,  M.  D.,  F.B.C.P.     In  one  IjJmovolume  of  97  pages.    Cloth,  $1.00. 


BROWNE  ON  KOCH'S  REMEDY  IN  RELATION 
TO  THROAT  CONSUMPTION.    In  one  octavo 


voum  ,  , 

which  are  colored,  and  11 I  charts     Cloth  $1.60 

win  I  TTR  ON  DISEASES  OF  THE  LUNdS  AINU 
AlfrPASSAGES  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment,  From  the 
second  ud  revised  English  edition  In  one 
octavo  volume  of  476  pages.  Cloth,  83.50 

SLADE  ON  DIPHTHERIA;  its  Nature  and  Treat. 
ment  with  an  account  of  the  History  of  it 


valence  in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  158  pp.     Cloth,  $1.28. 


TO  THROAT  CONSUMPTION.    In  one  octavo        eauion.     i 

volume  of  A  pages,  with  45  illustration!.,  4  of   SMITH  ON  CONSUMPTION ;  its  Early  and  Reme- 

voiume  01    *~*  ^"S^  ,       ,         ninth.  JM.RO.  ji_v,i~  a*.»«.      1  »nl    8vn    8.13  nn.     Cloth.  82.26. 


diable  Stages.    1  vol.  8vo.,  253  pp.    Cloth,  $2.26. 

LA  ROCHE  ON  PNEUMONIA.  1  rol.  8vo.  of  490 
pages.  Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration.  In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.60. 


Lea  Brothers  &  Co..  PubtishnTOS,  708  &  710  Sansom  Street,  Philadelphia. 


18       Nervous  and  flental  Diseases,  Histology. 


Dercum  on  Nervous  Diseases.— In  Press. 

A  Text-Book  on  Nervous  Diseases.  By  American  Authors.  Edited 
bv  F.  X.  DERCUM,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Nervous  System  in  the 
Jefferson  Medical  College,  Philadelphia.  In  one  handsome  octavo  volume  of  about 
1000  pages,  profusely  illustrated. 

LIST  OF  CONTRIBUTORS. 

N.  E.  BRII-L,  M.D. 

CHARLES  W.  BUEK,  M.D.  C.  A.  HERTER,  M.D. 

JOSEPH  COLLINS,  M.D.  GEORGE  W.  JACOBY,  M.D. 

CHARLES  L.  DANA,  M.D.  WILLIAM  W.  KK.KX,  M.D. 

PHILIP  COOMBS  KNAPP,  M.D. 

JAMES  HF.XHRIE  LLOYD,  M.D. 

CHARLES  K.  MILLS,  M.D. 


F.-X.  DERCUM.M.D. 
GEO.  K.  DE  SCHWEINITZ,  M.D. 
E.  D.  FISHER,  M.D. 
LAXDON  CARTER  GRAY,  M.D. 


S  WEIR  MITCHELL,  M.D. 
CHARLES  A.  OLIVER,  M.D. 
WILLIAM  OSLEU,  M.D. 
FREDERICK  PETERSON,  M.D. 
MORTON  PRINCE,  M.D. 
WHARTON  SINKLER.  M.D. 
M.  ALLEN  STARR,  M.D. 
JAMES  C.  WILSON,  M.  D. 


Gray  on  Nervous  and  Mental  Diseases. 

A  Practical   Treatise  on    Nervous    and   Mental  Diseases.    By 

LANDON  CARTER  GRAY,  M.  D.,  Professor  of  Diseases  of  the  Mind  and  Nervous  System 
in  the  New  York  Polyclinic.  In  one  very  handsome  octavo  volume  of  681  pages,  with 
168  illustrations.  Cloth,  $4.50;  leather,  $5.50. 

Mitchell  on  Nerve  Injuries  and  Their  Treatment.— In  Press. 

Remote  Consequences  of  Injuries  of  Nerves  and  Their  Treat- 
ment. An  examination  of  the  present  condition  of  wounds  received  in  1863-5,  with 
additional  illustrative  cases.  By  JOHN  K.  MITCHELL,  M.  D.,  Assistant  Physician  to  the 
Orthopaedic  Hospital  and  Infirmary  for  Nervous  Diseases,  Philadelphia.  In  one  hand- 
some 12mo.  volume  of  239  pages,  with  12  illustrations.  Cloth,  $1.75.  Just  ready. 

The  author  has  chosen  a  subject  of  great  clinical  importance  to  physicians  as  well  as  to 
surgeons.  Injuries  of  the  nerves  are  common  in  civil  as  well  as  in  military  life  and  lead  to 
various  painful  and  intractable  conditions.  Dr.  Mitchell  has  had  access  to  authentic  records 
covering  thirty  years,  and  his  researches  arrive  at  important  results  based  upon  an  ample 
number  of  cases  under  observation  for  a  prolonged  period. 

Ross  on  Diseases  of  the  Nervous  System. 

A  Handbook  on  Diseases  of  the  Nervous  System.  By  JAMES 
Boss,  M.  D.,  F.  R.  C.  P.,  LL.D.,  Senior  Assistant  Physician  to  the  Manchester  Royal 
Infirmary.  In  one  octavo  vol.  of  725  pages,  with  184  illus.  Cloth,  $4.50 ;  leather,  $5.50. 

which    it   treats.    In  every  part   this  handbook 
merits  the  highest  praise,  and  will  no  doubt  be 


This  admirable  work  is  intended  for  students  of 
medicine  and  for  such  medical  men  as  have  no  time 
for  lengthy  treatises.  It  is  a  concise  and  philo- 
sophical guide  to  the  department  of  medicine  of 


found  of  the  greatest  value  to  the  student  as  well 
as  to  the  practitioner. — Edinburgh  Medical  Journal. 


Hamilton  on  Nervous  Diseases.— Second  Edition. 

Nervous  Diseases ;  Their  Description  and  Treatment.  By  ALLEN  McLANE 
HAMILTON,  M.  D.,  Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics, 
Blackwell's  Island,  N.  Y.  Second  edition,  thoroughly  revised  and  rewritten.  In  one 
octavo  volume  of  598  pages,  with  72  illustrations.  Cloth,  $4.00. 

Savage  on  Insanity  and  Allied  Neuroses. 

Insanity  and  Allied  Neuroses,  Practical  and  Clinical.  By  GEORGE 
H.  SAVAGE,  M.  D.,  Lecturer  on  Mental  Diseases  at  Guy's  Hospital,  London.  In  one 
12mo.  vol.  of  551  pp.,  with  18  illus.  Cloth,  $2.00.  See  Series  of  Clinical  Manuals,  p.  30. 

Klein's  Histology.— Fourth  Edition. 

Elements  of  Histology.  By  E.  KLEIN,  M.  D.,  F.  R.  S.,  Joint  Lecturer  on 
General  Anatomy  and  Physiology  in  the  Medical  School  of  St.  Bartholomew's  Hospital, 
London.  Fourth  edition.  In  one  12mo.  volume  of  376  pages,  with  194  illus.  Limp 
cloth,  $1.75.  See  Students?  Series  of  Manuals,  page  30. 

The  large  number  of  editions  through  which  ' 
Dr.  Klein's  little  handbook  of  histology  has  run 
since  its  first  appearance  in  1883  is  am  pie  evidence 
that  it  is  appreciated  by  the  medical  student  and 
that  it  supplies  a  definite  want.    The  clear  and 


concise  manner  in  which  it  is  written,  the 
absence  of  debatable  matter,  of  conflicting  views, 
added  to  the  convenient  size  of  the  book  and  its 
moderate  price,  will  account  for  its  undoubted 
success. — Medical  Chronicle. 


Schafer's  Histology.— Third  Edition. 

The  Essentials  of  Histology.  By  EDWARD  A.  SCHAFER,  F.  R.  S.,  Jodrell 
Professor  of  Physiology  in  University  College,  London.  New  (third)  edition.  In  one 
octavo  volume  of  311  pages,  with  325  illustrations.  Cloth,  $3.00. 


BLANDFORD  ON  INSANITY  AND  ITS  TREAT- 
MENT. Lectures  on  the  Treatment,  Medical 
and  Legal,  of  Insane  Patients.  In  one  very 
handsome  octavo  volume. 

JONES'  CLINICAL  OBSERVATIONS  ON  FUNC- 
TIONAL NERVOUS  DISORDERS.  Second 


American  Edition.  In  one  handsome  octavo 
volume  of  340  pages.  Cloth,  83.25. 
PEPPER'S  SURGICAL  PATHOLOGY.  In  one 
pocket-size  12mo.  volume  of  511  pages,  with  81 
illustrations.  Limp  cloth,  red  edges,  32.00  See 
Students'  Series  of  Manuals,  page  30. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Pathology,  Histology,  Bacteriology. 


19 


Abbott's  Bacteriology.—  New  (2d)  Edition.    Just  Ready. 

The  Principles  of  Bacteriology  :  a  Practical  Manual  for  Students  and 
Physicians.  By  A.  C.  ABBOTT,  M.  D.,  First  Assistant,  Laboratory  of  Hygiene,  University 
of  Pennsylvania,  Philadelphia.  New  (2d)  edition,  thoroughly  revised  and  greatly 
enlarged.  In  one  very  handsome  12mo.  volume  of  472  pages,  with  94  illustrations  of 
which  17  are  colored. 


Cloth,  $2.75. 

Its  scope  has  been  much  extended,  so  that  it  tionp,  partly  colored,  are  helpful  in  the  elucidation 

now  contains  all  that  is  necessary  for  a  beginner  of  the    text.    Ample   instruction    is  given  as  to 

to    learn  in    order  to   gain  a  practical    working  needed  apparatus,  cultures,  stainings,  microscop- 

knowledge    of    the   subject.      It   is   particularly  ic  examinations,  etc.    The  pathogenic  bacilli  are 

adapted  to  the  wants  of  students  and  practitioners  fully  described  both  by  the  text  and  illustrations 

who  wish  to  pursue  their  study  without  the  aid  of  and  the  methods  of  conducting  examinations  are 

an  instructor.—  Medicine,  April,  1895.  fully  set  forth.    It  will  win  its  way  and  become  a 

The  instructions  for  methods  of  work  are  all  favorite.—  Virginia    Medical  Monthly.    November 

lucid  and  concise.    It  is  the  most  satisfactory  and  1894. 

comprehensive  book  on  practical  bacteriology  in        On  the  whole  the  book  is  one  of  the  best  of  its 

our  language.  —  Chicago  Clinical  Review,  Nov.,  1894.  kind  and  the  most  practical  in  the  English  lan- 

The  second  edition  has  been  much  enlarged  by  guage.  —  Maryland  Medical  Journal,  Nov.  3,  1894. 
the  addition  of  much  new  matter.    Its  illustra- 


Gibbes'  Practical  Pathology  and  Morbid  Histology. 

Practical  Pathology  and  Morbid  Histology.  By  HENEAGE  GIBBES, 
M.  D.,  Professor  of  Pathology  in  the  University  of  Michigan,  Medical  Department.  In 
one  very  handsome  8vo.  vol.  of  314  pp.,  with  60  illus.,  mostly  photographic.  Cloth,  $2.75. 

-' 


In  fulness  of  directions  as  to  the  modes  of 
investigating  morbid  tissues  the  book  leaves 
little  to  be  desired.  The  work  is  throughout 
profusely  illustrated  with  reproductions  of  micro- 
photographs.  We  may  say  that  the  practical 
histologist  will  gain  much  useful  information 
from  the  book. —  The  London  Lancet. 

The  student  of  morbid  histology  and  bacteri- 
ology has  at  his  hand,  in  this  neat  volume  of  some 
three  hundred  pages,  a  most  excellent  guide  and 
one  which,  unless  ne  be  a  very  advanced  student, 
he  cannot  afford  to  be  without.  The  work  is 
divided  into  four  parts,  the  first,  that  of  practical 
pathology,  containing  clear  and  precise  directions 
in  histological  technique,  showing  how  to  prepare 


the  tissues  for  examination,  cut,  stain  and  mount 
sections,  etc.  The  second  part  deals  with  bacteri- 
ology, with  the  different  forms  of  cultivation, 
microscopic  examinations  of  the  bacteria,  etc. 
The  third  part,  which  comprises  more  than  half 
the  book,  treats  of  morbid  histology.  This  part  is 
illustrated  wi(.h  a  great  number  of  beautiful  photo- 
micrographs in  which  the  microscopic  field  is 
reproduced  with  a  distinctness  that  is  really 
remarkable.  The  fourth  part  contains  some  very 
practical  instruction  on  photography  with  the 
microscope.  Works  like  this  of  Dr.  Gibbes  will  soon 
popularize  histology  among  the  profession  at  large, 
whereas  it  is  now  to  a  large  number  of  physicians 
almost  a  sealed  book. — Medical  Record. 


Senn's  Surgical  Bacteriology.— Second  Edition. 

Surgical  Bacteriology.  By  NICHOLAS  SENN,  M.  D.,  Ph.  D.,  Professor  of 
Surgery  in  Rush  Medical  College,  Chicago.  New  (second)  edition.  In  one  handsome 
octavo  of  268pp.,  with  13  plates,  of  which  10  are  colored,  and  9  engravings.  Cloth,  $2.00. 


The  book  is  really  a  systematic  collection  in  the 
most  concise  form  of  such  results  as  are  published 
in  current  medical  literature  by  the  ablest  workers 
in  this  field  of  surgical  progress ;  and  to  these  are 
added  the  author's  own  views  and  the  results  of 
his  clinical  experience  and  original  investigations. 
The  book  is  valuable  to  the  student,  but  its  chief 
value  lies  in  the  fact  that  such  a  compilation 


makes  it  possible  for  the  busy  practitioner,  whose 
time  for  reading  is  limited  and  whose  sources  of 
information  are  often  few,  to  become  conversant 
with  the  most  modern  and  advanced  ideas  in  sur- 
gical pathology,  which  have  "laid  the  foundation 
for  the  wonderful  achievements  of  modern  sur- 
gery."— Annal-i  of  Surgery. 


Green's  Pathology  and  Morbid  Anatomy.— Seventh  Edition. 

Pathology  and  Morbid  Anatomy.  By  T.  HENRY  GREEN,  M.  D.,  Lecturer 
on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hospital  Medical  School,  London. 
Sixth  American  from  the  seventh  and  revised  English  edition.  Octavo,  539  pages,  with 
167  engravings.  Cloth,  $2.75. 

The  Pathology  and  Morbid  Anatomy  of  Dr. 
Green  Is  too  well  known  by  members  of  the  medi- 
cal profession  to  need  any  commendation.  There 
is  scarcely  an  intelligent  physician  anywhere  who 
has  not  the  work  in  his  library,  for  it  is  almost  an 
essential.  In  fact  it  is  better  adapted  to  the  wants 
of  general  practitioners  than  any  work  of  the  kind 
with  which  we  are  acquainted.  The  works  of 
German  authors  upon  pathology,  which  have  been 

Coats'  Treatise  on  Pathology. 

A  Treatise  on  Pathology.  By  JOSEPH  COATS,  M.  D.,  F.  F.  P.  S.,  Patholo- 
gist to  the  Glasgow  Western  Infirmary.  In  one  very  handsome  octavo  volume  of  829 
passes,  with  339  beautiful  illustrations.  Cloth,  $5.50 ;  leather,  $6.50. 

Medical  students  as  well  aa  physicians,  who  |  manner,  the  changes  from  a  normal  condition 
desire  a  work  for  study  or  reference,  that  treats  effected  in  structures  by  disease,  and .point*  put 
the  subjects  in  the  various  departments  in  a  very  the  characteristics  of  various  morbid  agencies 
:horogi  manner,  but  without  prolixity,  will  cer-  so  that  they  can  be  easily  recognized.  But,  not 
taTnly  tivHhis  one  the  preference  to  any  with  limited  to  morbid  anatomy  it  explains  fully  how 
wS  we  are  acquainted  It  gets  forth  the  most  the  functions  of  organs  are  disturbed  by  abnormal 
recent  discoveries,  exhibits,  in  an  interesting  |  conditions.- Cincinnati  Mriical  News. 


translated  into  English,  are  too  abstruse  for  the 
physician.  Dr.  Green's  work  precisely  meets  his 
wishes.  The  cuts  exhibit  the  appearances  of 
pathological  structures  just  as  they  are  seen 
through  the  microscope.  The  fact  that  it  is  so 
generally  employed  as  a  text-book  by  medical  stu- 
dents is  evidence  that  we  have  not  spoken  too 
much  in  its  favor. — Cincinnati  Medical  News. 


PAYNE'S  MANUAL  OF  GENERAL  PATHOL- 
OGY. Designed  as  an  Introduction  to  the  Prac- 
tice of  Medicine.  By  JOSEPH  F.  PAYNE,  M.  D., 


F.  R.  C.  P.,  Lecturer  on  Pathological  Anatomy, 
St.  Thomas'  Hospital,  London. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


20 


Surgery. 


Ashhurst's  Surgery.— Sixth  Edition. 

The  Principles  and  Practice  of  Surgery.  By  JOHN  ASHHURST,  JR. 
M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the  Univ.  of  Penna.,  Surgeon  to  the 
Penna.  Hospital,  Philadelphia.  Sixth  edition,  enlarged  and  thoroughly  revised. 
Octavo,  1161  pages,  656  engravings  and  a  colored  plate.  Cloth,  §6.00;  leather,  $7.00. 

Ashhursfs  Surgery  main  tains  in  its  sixth  edition  '  merit  a  continuance  of  the  confidence  of  theprofes- 
the  high  standard  of  excellence  which  has  always  ,  sion.  Jn  this  edition  he  has  incorporated  an  ac- 
been  its  characteristic.  The  author  has  so  thor-  ;  countof  the  more  important  recent  observations  in 
oughly  rt  vised  his  work  that  the  most  recent  j  surgical  science,  as  well  as  such  novelties  in  sur- 
appliances  and  methods  in  surgery  are  mentioned,  j  gical  practice  as  meritthe  classification  of  improve- 
Dr.  Ashhurst's  well-known,  comprehensive,  and  i  ments.  Dr.  Charles  B.  Nancrede,  of  Ann  Arbor, 
yet  concise  treatment  of  the  various  subjects  is  |  has  contributed  a  new  chapter  on  surgical  bacteri- 
even  more  marked  in  this  than  in  the  previous  i  ology;  Dr.  Barton  C.  Hirst  has  revised  the  sections 
editions.  A  great  deal  of  new  matter  has  been  I  on  gynecological  subjects;  and  Drs.  George  E. 
added.—  The  Chicago  Medical  Recorder.  i  de  Schweinitz  and  B.  Alexander  Randall  have  re- 

The  author  has  been  before  the  surgical  world  !  vised  the  chapters  on  diseases  of  the  eye  and  ear. 
so  long  and  is  so  versatile  and  resourceful  that  j  Those  surgeons  who  possess  earlier  editions  of 
his  several  editions  are  rapidly  taken  up.  Ashhurst's  treatise  will  make  haste  to  obtain  this 
Ashhurst  has  taken  great  pains  to  render  this  new  one.  and  those  who  are  not  familiar  with  the 
sixth  edition  fully  equal  to  the  demands  of  the  work  will  necessarily  add  it  to  their  libraries, 
present*,  and  has  constructed  it  on  lines  which  I — Buffalo  Medicni  and'Surqical  Journal. 

Young's  Orthopedic  Surgery. 

A  Manual  of  Orthopedic  Surgery,  for  Students  and  Practi- 
tioners. By  JAMES  K.  YOUNG,  M.  D.,  Instructor  in  Orthopaedic  Surgery,  University  of 
Pennsylvania,  Philadelphia.  In  one  octavo  volume  of  446  pages,  with  285  illustrations. 
Cloth,  $4 ;  leather,  35. 

The  present  work  will  be  found  to  meet  a  want  approved  modern  views,  and  the  treatment  is 
among  students  in  acquiring  a  knowledge  of  the  very  thoroughly  and  comprehensively  considered, 
subject,  and  among  practitioners  who  constantly  Especial  attention  has  been  given  to  the  mechani- 
see  a  greater  or  less  number  of  deformities  and  cal  part  of  the  subject.  A  very  valuable  feature 
who  desire  information  regarding  the  most  of  the  work  is  the  large  number  of  excellently- 
recent  views  on  the  pathology  and  treatment  of  executed  drawings  which  illustrate  the  text.  In 
this  subject.  Dr.  Young's  large  experience  has  those  cases  in  which  doubt  is  apt  to  occur,  or  in 
particularly  fitted  him  for  the  preparation  of  this  which  the  symptoms  may  be  obscure,  the  differ- 
work,  which  is  based  upon  his  personal  observa-  ential  diagnosis  has  been  very  fully  given.  This 
tions,  although  the  literature  of  the  subject  has  ;  ground  has  been  well  covered,  and  the  work 
been  carefully  sifted,  and  whatever  of  import-  may  be  relied  upon  as  reflecting  the  present 
ance  he  has  thus  obtained  has  been  made  full  position  of  the  subject  of  which  it  treats. — '" 
use  of,  due  credit  being  given.  The  pathology  versity  Medical  Magazine,  January,  1895. 
will  be  found  to  correspond  with  the  most 

Roberts'  Modern  Surgery. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Stu- 
dents and  Practitioners  of  Medicine  and  Surgery.  By  JOHN  B.  ROBERTS,  M.  D.,  Prof,  of 
Anatomy  and  Surgery  in  the  Philadelphia  Polyclinic.  Prof,  of  Surgery  in  the  Woman's 
Medical  College  of  Pennsylvania.  Lecturer  in  Anatomy  in  the  Univ.  of  Penna.  Octavo, 
780  pages,  501  illustrations.  Cloth,  $4.50 ;  leather,  $5.50. 

the  leading  practitioners  of  the  art,  and  its  liter- 
ature is  fully  up  to  all  the  advanced  doctrines  and 


This  work  is  a  very  comprehensive  manual  upon 
general  surgery.  It  has  a  thoroughly  practical 
character,  the  subjects  are  treated  with  rare  judg- 
ment, its  conclusions  are  in  accord  with  those  of 


methods  of  practice  of  the  present  day. — Medical 
Record. 


Druitt's  Modern  Surgery.— Twelfth  Edition. 

Manual  of  Modern  Surgery.  By  ROBERT  DRUITT,  M.  R.  C.  S.  Twelfth 
edition,  thoroughly  revised  by  STANLEY  BOYD,  M.  B.,  B.  S.,  F.  R.  C.  S.  In  one  8vo. 
volume  of  965  pages,  with  373  illustrations.  Cloth,  $4.00;  leather,  $5.00. 

Holmes'  Treatise  on~Surgery.— Fifth  Edition. 

A  Treatise  on  Surgery ;  Its  Principles  and  Practice.  By  TIMOTHY 
HOLMES,  M.  A.,  Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 
From  the  fifth  English  edition,  edited  by  T.  PICKERING  PICK,  F.  R.  C.  S.  In  one 
octavo  volume  of  997  pages,  with  428  illustrations.  Cloth,  $6.00;  leather,  $7.00. 


MARSH  ON  THE  JOINTS.  In  one  12mo.  volume 
of  468  pages,  with  04  woodcuts  and  a  colored 
plate.  Cloth,  32.00.  See  Striesof  Clinical  Manual*, 
page  30. 

BUTLIN  ON  DISEASES  OF  THE  TONGUE.  By 
HENBY  T.  BUTLIN,  F.  R.  C.  S.,  Assistant  Surgeon 
to  St.  Bartholomew's  Hospital,  London.  In  one 
12mo.  volume  of  466  pages,  with  8  colored  plates 
and  3  woodcuts.  Cloth,  $3.50.  See  Series  of  Clin- 
ical Manuals,  page  30. 

GOULD'S  ELEMENTS  OF  SURGICAL  DIAG- 
NOSIS. By  A.  PEARCE  GOULD,  M.  S.,  M.  B., 
F.  R.  C.  S.,  Assistant  Surgeon  to  Middlesex  Hos- 
pital, London.  In  one  pocket-size  12mo.  volume 
of  589  pages.  Cloth,  $2.00.  See  Students'  Series 
of  Manuals,  page  30. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth 
and  revised  American  edition.  In  one  large  8vo. 


vol.  of  682  pp..  with  364  illustrations.    Cloth, $3.75. 

MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  ed.  In  one 
8vo.  vol.  of  638  pages,  with  340  illus.  Cloth,  $3.75. 

PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  JOHN  NEILL,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.  Cloth,  $3.75. 

GANT'S  STUDENT'S  SURGERY.  By  FREDERICK 
JAMES  GAXT,  F.  R.  C.  S.  Square  octavo,  848  pages, 
159  engravings.  Cloth,  83.75. 

HOLMES'  SYSTEM  OF  SURGERY.  THEORET- 
ICAL AND  PRACTICAL.  By  Various  Authors. 
Edited  by  TIMOTHY  HOLMES,  M.  A.  American  edi- 
tion, revised  and  re-edited  by  JOHN  H.  PACKARD, 
M.  D.  Three  large  octavo  volumes,  3137  pages, 
979  illustrations  on  wood  and  13  lithographic 
plates.  Per  set,  cloth,  818.00;  leather,  $21.00 
Subscription  only. 


Lea  Brothers  &  Co.,  Publishers.  706,  708  &  710  Sansom  Street,  Philadelphia. 


Surgery — (Continued).  21 

Wharton's  Minor  Surgery  and  Bandaging.— Secondd  Edition. 

Minor  Surgery  and  Bandaging.  By  HENRY  E.  WHARTON,  M.  D., 
Demonstrator  of  Surgery  in  the  University  of  Pennsylvania.  In  one  12mo.  volume  of 
529  pages,  with  416  engravings,  many  being  photographic.  Cloth,  $3.00. 

The  book  is  one  of  the  very  best  treatises  on  localities  of  the  body.  The  author  has  thoroughly 
minor  surgery  and  it  ought  to  be  adopted  as  a  ,  revised  that  portion  of  the  work  relating  to  the 
text- book  on  the  subjects  of  which  it  treats.  It  aseptic  and  antiseptic  methods  of  wound  treat- 
contains  more  practical  surgery  within  its  limits  ment,  than  which  there  is  no  more  important 
and  boundaries  than  any  book  of  its  kind  \ve  have  subject  in  the  whole  domain  of  surgery.  Much 
ever  seen.  Its  illustrations  are  to  be  specially  ;  new  matter  has  been  added,  which  brings  it 
commended,  particularly  those  that  relate  to  abi east  of  the  very  latest  knowledge  on  the  sub- 
bandaging,  most  of  which  have  been  taken  from  jects  of  which  it  treats.— Buffalo  Mtdieal  and  Sur- 
photographs  of  applied  bandages  in  the  several  :  gical  Journal. 

Treves'  Operative  Surgery.— Two  Volumes. 

A  Manual  of  Operative  Surgery.  By  FREDERICK:  TREVES,  F.RC.S., 
Surgeon  and  Lecturer  on  Anatomy  at  the  London  Hospital.  In  two  octavo  volumes 
containing  1550  pages,  with  422  engravings.  Complete  work,  cloth,  $9.00;  leather,  $11.00. 

not  fail  to  be  of  the  greatest  use  both  to  practical 


Mr.  Treves  in  this  admirable  manual  of  opera- 
tive surgery  has  in  each  instance  practically 
assumed  that  operation  has  been  decided  upon 
and  has  then  proceeded  to  give  the  various  opera- 
tive methods  which  may  be  employed,  with  a 
criticism  of  their  comparative  value  and  a  detailed 


of  their  performance.  Especial  attention  has  been 
paid  to  the  preparatory  treatment  of  the  patient 
and  to  the  details  of  the  after  treatment  of  the 
case,  and  this  is  one  of  the  most  distinctive  among 
the  many  excellent  features  of  the  book.  We  have 
no  hesitation  in  declaring  it  the  best  work  on  the 
subject  in  the  English  language,  and  indeed,  in 
many  respects,  the  best  in  any  language.  It  can- 


surgeons  and  to  those  general  practitioners  who, 
owing  to  their  isolation  or  to  other  circumstances, 
are  forced  to  do  much  of  their  own  operative  work. 
We  feel  called  upon  to  recommend  the  book  so 
strongly  for  the  excellent  judgment  displayed  in 
the  arduous  task  of  selecting  from  among  the 
thousands  of  varying  procedures  those  most 
worthy  of  description ;  for  the  way  in  which  the 
still  more  difficult  task  of  choosing  among  the 
best  of  those  has  been  accomplished;  and  for  the 
simple,  clearj  straightforward  manner  in  which 
the  information  thus  gathered  from  all  surgical 
literature  has  been  conveyed  to  the  reader. — 
Annals  of  Surgery. 


Treves'  Student's  Handbook  of  Surgical   Operations.     In  one 

square  12mo.  volume  of  508  pages,  with  94  illustrations.     Cloth,  $2.50. 

A  Manual  of  Surgery.  In  Treatises  by  Various  Authors,  edited  by  FRED- 
ERICK TREVES,  F.  K.  C.  S.  In  three  12mo.  volumes,  containing  1866  pages,  with  213 
engravings.  Price  per  set,  cloth,  $6.00.  See  Students?  Series  of  Manuals,  page  30. 

Treves  on  Intestinal  Obstruction.  In  one  12mo.  volume  of  522  pages, 
with  60  ill  us.  Limp  cloth,  blue  edges,  $2.00.  See  Series  of  Clinical  Manuals,  page  30. 

Smith's  Operative  Surgery.— Revised  Edition. 

The  Principles  and  Practice  of  Operative  Surgery.  By  STEPHEN 
SMITH,  M.  D.,  Professor  of  Clinical  Surgery  in  the  University  of  the  City  of  New  York. 
Second  and  thoroughly  revised  edition.  In  one  very  handsome  octavo  volume  of  892 
pages,  with  1005  illustrations.  Cloth,  $4.00;  leather,  $5.00. 

This  excellent  and  very  valuable  book  is  one  of  surgeon,  and  even  as  a  book  of  reference  for  the 
the  most  satisfactory  works  on  modern  operative  physician  not  especially  engaged  in  the  practice 
surgery  yetpublished.  The  book  is  a  compendium  I  of  surgery,  this  volume  will  long  hold  a  most 
for  the  modern  surgeon.  The  present  edition  is  conspicuous  place,  and  seldom  will  its  readers,  no 
much  enlarged,  and  the  text  has  been  thoroughly  matter  how  unusual  the  subject,  consult  its  pages 
revised  so  as  to  give  the  most  improved  methods  in  vain.  Its  compact  form,  excellent  print,  num- 
in  aseptic  surgery,  and  the  latest  instruments  erous  illustrations,  and  especially  its  decidedly 
known  for  operative  work.  Itcan  be  truly  said  that  practical  character,  all  combine  to  commend  it.— 
as  a  handbook  for  the  student,  acompanion  for  the  |  Boston  Medical  and  Surgical  Journal. 

Erichsen's  Science  amTlrt  of  Surgery.— Eighth  Edition. 

The  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries, 
Diseases  and  Operations.  By  JOHN  E.  ERICHSEN,  F.  K.  S.,  F.  K.  C.S.,  Professor  of  Sur- 
gery in  University  College,  London,  etc.  From  the  eighth  and  enlarged  English  edition. 
In  two  large  8vo.  vols.  of  2316  pp.,  with  984  engravings  on  wood.  Cloth,  $9 ;  leather,  $11. 

Bryant's  Practice  of  Surgery.— Fourth  Edition. 

The  Practice  of  Surgery.  By  THOMAS  BRYANT,  F.  E.  C.  S.,  Surgeon  and 
Lecturer  on  Surgery  at  Guy's  Hospital,  London.  Fourth  American  from  the  fourth  and 
revised  English  edition.  In  one  large  and  very  handsome  imperial  octavo  volume  of  1040 
pages,  with  727  illustrations.  Cloth,  $6.50;  leather,  $7.50. 

-    -  

Ball  on  the  Rectum  and  Anus.— New  Edition. 

The  Rectum  and  Anus,  Their  Diseases  and  Treatment.  BY 
CHARLES  B.  BALL,  F.  R  C.  S.,  University  Examiner  in  Surgery  Dublin  In  one  lino, 
volume  of  453  pages,  with  60  engravings  and  4  colored  plates.  Cloth,  $2.25.  Just  ready. 
See  Series  of  Clinical  Manual?,  p.  30. 

Lea  Brothers  &  Co.,  Publishers.  706,  708  &  710  Sansom  Street,  Philadelphia. 


22     Surgery — (Continued),  Fractures,  Dislocations. 


Vol.  I.  Just  Ready.    Vol.  II.  Shortly.    Vols.  III.  and  IV.  Preparing. 

A   SYSTEM   OF   SURGERY. 

BY    AMERICAN    AUTHORS. 

Edited  by  FREDERIC  S.  DENNIS,  M.D.,  Professor  of  the  Principles  and  Practice 
of  Surgery,  Bellevue  Hospital  Medical  College,  New  York ;  President  of  the  American 
Surgical  Assaciation,  etc.  Assisted  by  JOHX  S.  BILLINGS,  M.D.,  LL.D,  D.C.L.,  Deputy 
Surgeon-General,  U.  S.  A.  In  four  imperial  octavo  volumes  of  about  900  pages  each, 
prolusely  illustrated  in  black  and  colors.  Price  per  volume,  cloth,  §6  ;  leather,  $7  ;  half 
Morocco,  gilt  back  and  top,  $8.50.  -For  sale  by  subscription  only.  Address  the  Publishers. 


-     LIST    OF    CONTRIBUTORS. 


ROBERT  ABBE,  M.D., 
GOKHAM  BACON,  M.D. 
HERMAN  M.  BIGGS,  M.D., 
JOHN  8.  BILLINGS,  M.D., 
WILLIAM  T.  BULL,  M.D., 
WILLIAM  H.  CARMALT,  M.D  , 
HENRY  C.  COE,  M.D., 
P.  S.  CONNER,  M.D., 
WILLIAM  T.  COUNCILMAN,  M.D., 
D.  BRYSON  DELAVAN,  M.D., 
FREDERIC  S  DENNIS,  M  D., 
EDWARD  K.  DUNHAM,  M.D  , 
WILLIAM  H.  FORWOOD,  M.D., 
GEORGE  R.  FOWLER,  M.D., 
FREDERICK  H.  GERRISH,  M.D., 
ARPAD  G.  GERSTER,  M.D., 


VIRGIL  P.  GIBNEY,  M.D., 
WILLIAM  A.  HARDAWAY.  M.D., 
FRANK  T.  HARTLEY,  M.D., 
JOSEPH  TABER  JOHNSON,  M.D., 
WILLIAM  W.  KEEN,  M.D., 
WILLIAM  T.  LUSK,  M.D., 
CHARLES  MCBURNEY,  M.D., 
RUDOLPH  MATAS,  M.D., 
HENRY  H.  MUDD,  M.D., 
CHARLES  B.  NANCREDE,  M.D., 
HENRY  D.  NOYES,  M.  D., 
ROSWELL  PARK,  M.D , 
WILLARD  PARKER,  M.D., 
LEWIS  8.  PILCHER,  M.D., 
WILLIAM  H.  POLK,  M.D., 


CHARLES  H.  PORTER,  M.D., 
MAURICE  H.  RICHARDSON,  M.D., 
JOHN  B.  ROBERTS,  M.D., 
GEORGE  E.  DE  SCHWEINITZ,  M.D., 
NICHOLAS  SENN,  M.D., 
STEPHEN  SMITH,  M.D., 
LEWIS  A.  STIMSON,  M.D., 
ROBERT  W.  TAYLOR,  M.D., 
Louis  McL.  TIFFANY,  M.D., 
J.  COLLINS  WARREN,  M.D., 
HENRY  R.  WHARTON,  M.D., 
ROBERT  F.  WEIR,  M.D., 
WILLIAM  H.  WELCH,  M.D., 
J.  WILLIAM  WHITE,  M.D., 
HORATIO  C.  WOOD,  M.D., 


Hamilton  on  Fractures  and  Dislocations.— Eighth  Edition. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  By  FRANK 
H.  HAMILTON,  M.  D.,  LL.  D.,  Surgeon  to  Bellevue  Hospital,  New  York.  New  (8th)  edi- 
tion, revised  and  edited  by  STEPHEN  SMITH,  M.  D.,  Prof,  of  Clinical  Surgery  in  Univ.  of 
City  of  N.  Y.  In  one  octavo  volume  of  832  pp.,  with  507  illus.  Cloth,  $5.50 ;  leather,  $6.50. 
Its  numerous  editions  are  convincing  proof  if  any  j  ject  of  such  magnitude  is  no  easy  one.  Dr.  Smith 
is  needed,  of  its  value  and  popularity.  It  is  pre-  has  aimed  to  make  the  present  volume  a  correct 
eminently  the  authority  on  fractures  and  disloca-  exponent  of  our  knowledge  of  this  department 
tions,  and  universally  quoted  as  such.  In  the  new  I  of  surgery.  The  more  one  reads  the  more 
edition  it  has  lost  none  of  its  former  worth.  The  I  one  is  impressed  with  its  completeness.  The  work 


additions  it  has  received  by  its  recent  revision  make 
it  a  work  thoroughly  in  accordance  with  modern 
practice,  theoretically,  mechanica'ly,  aseptically. 
The  task  of  writing  a  complete  treatise  on  a  sub- 


has  been  accomplished,  and  has  been  done  clearly, 
concisely,  excellently  well.— Boston  Medical  and 
Surgical  Journal. 


Stimson  on  Fractures  and  Dislocations. 

A  Treatise  on  Fractures  and  Dislocations.  By  LEWIS  A.  STIMSON, 
M.  D.  In  two  handsome  octavo  volumes.  Vol.  I.,  FRACTURES,  582  pages,  360  illustra- 
tions. Vol.  II.,  DISLOCATIONS,  540  pages,  with  163  illustrations.  Complete  work, 
cloth,  $5.50 ;  leather,  $7.50.  Either  volume  separately,  cloth,  $3.00 ;  leather,  $4.00. 

The  appearance  of  the  second  volume  marks  the  exhibits  the  surgery  of  Dislocations  as  it  is  taught 
completion  of  the  author's  original  plan  of  prepar-  and  practised  by  the  most  eminent  surgeons  of  the 
ing  a  work  which  should  present  in  the  fullest  present  time.  Containing  the  results  of  such  ex- 
manner  all  that  is  known  on  the  cognate  subjects  tended  researches  it  must  for  a  Jong  time  be  re- 
of  Fractures  and  Dislocations.  The  volume  on  garded  as  an  authority  on  all  subjects  pertaining 
Fractures  assumed  at  once  the  position  of  authority  to  dislocations.  Every  practitioner  of  surgery  will 
on  the  subject,  and  its  companion  on  Dislocations  feel  it  incumbent  on  him  to  have  it  for  constant 
will  no  doubt  be  similarly  received.  This  volume  .  reference. — Cincinnati  Medical  News. 

Stimson's  Operative  Surgery.— Second  Edition. 

A  Manual  of  Operative  Surgery.  By  LEWIS  A.  STIMSON,  B.  A.,  M.  D., 
Professor  of  Clinical  Surgery  in  the  University  of  the  City  of  New  York.  Second  edi- 
tion. In  one  royal  12mo.  volume  of  503  pages,  with  342  illustrations.  Cloth,  $2.50. 

Cheyne  on  Wounds,  Ulcers  and  Abscesses.— Just  Ready. 

The  Treatment  of  Wounds,  Ulcers  and  Abscesses.  By  W.WATSON 
CHEYNE,  M.  B.,  F.  R.  S.,  F.  R.  C.  S ,  Professor  of  Surgery  in  King's  College,  London.  In 
one  12mo.  volume  of  207  pages.  Cloth,  $1.25. 

Pick  on  Fractures  and  Dislocations. 

Fractures  and  Dislocations.  By  T.  PICKERING  PICK,  F.  R.  C.  S.,  Sur- 
geon to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London 

_r  COA  «•.        ,,-ttl,    QO   ;l  1,,£.          T  I..**,   ,.l,,tU     (tO  Art         (2nA     C,.~.'M/.    ^f    S*?J*~.~* 


of  530  pp.,  with  93  illus.     Limp  cloth,  $2.00. 


In   one    12mo.   vol. 
See  Series  of  Clinical  Manuals,  page  30. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Ophthalmology. 


23 


Norris  &  Oliver's  Ophthalmology. 

A  Text-Book  of  Ophthalmology.  By  WILLIAM  F.  NORRIS,  M.  D., 
Professor  of  Ophthalmology  in  the  University  of  Pennsylvania,  and  CHARLES  A.  OLIVER, 
M.  D.,  Surgeon  to  Wills'  Eye  Hospital,  Philadelphia.  In  one  very  handsome  octavo 
vol.  of  632  pages,  with  357  engravings  and  5  colored  plates.  Cloth,  $5 ;  leather,  $6. 

This  is  the  first  text-book  of  diseases  of  the  eye  I  to  any  would-be  competitor.  Wonderfully  cheap 
written  by  American  authors  for  American  col-  j  in  price,  beautifully  printed  and  exquisitely  illus- 
leges  and  students.  Rules  and  procedures  are  trated,  the  mechanical  make-up  or  the  book  is 
made  so  plain  and  so  evident  that  any  student  j  all  that  can  be  desired.  After  most  conscientious 
can  easily  understand  and  employ  them.  It  is  j  and  painstaking  perusal  of  the  work,  we  unre- 
succinct  in  recital,  practical  in  its  teachings,  judi-  !  servedly  endorse  it  as  the  best,  the  safest  and  the 
cious  in  the  selection  of  material  and  conservative, 
yet  radical  when  necessary.  In  treatment  it  can 
be  accepted  as  from  the  voice  and  the  pen  of  a 
respec£ed  and  recognized  authority.  The  illus- 


trations far  outnumber  those  of  its  contempora- 
ries, whilst  the  high  grade  and  unbiased  opinions 
of  the  teachings  serve  to  give  it  a  rank  superior 


most  comprehensive  volume  upon  the  subject  that 
has  ever  been  offered  to  the  American  medical 
public.  We  sincerely  hope  that  it  may  find  its 
way  into  the  list  of  text-books  of  every  English- 
speaking  college  of  medicine.— Annals  of  Ophthal- 
mology and  Otology. 


Berry  on  the  Eye.— New  (2d)  Edition. 

Diseases  of  the  Eye.  A  Practical  Treatise  for  Students  of  Ophthalmology. 
By  GEORGE  A.  BERRY,  M.  B.,  F.  E.  C.  S.,  Ed.,  Ophthalmic  Surgeon,  Edinburgh  Royal 
Infirmary.  New  (second)  edition.  In  one  octavo  volume  of  750  pages,  with  197  illustra- 
tions, mostly  lithographic.  Cloth,  $8.00. 

This  is  by  far  the  best  work  upon  its  theme  in 
the  English  language  that  we  have  seen,  for  the 
diction  is  pure  and  clear,  and  besides,  the  beauti- 
ful illustrations  of  normal  and  diseased  conditions 
make  it  a  valuable  addition  to  the  library  of  all 
practitioners,  general  as  well  as  special.  We  have 
never  seen  more  real  delineation  of  disease,  the 


coloring  is  perfect,  and  each  illustration  is  an 


"object-lesson."  We  cannot  but  reiterate  what  we 
sai«i  at  the  beginning,  that  we  have  had  great  pleas- 
ure in  the  perusal  of  this  work,  and  great  profit,  and 
that  we  consider  it  the  best  on  the  subject  in  the 
English  language  to-day,  not  only  for  its  diction 
but  for  its  instructive  illustrations. —  The  American 
Journal  of  the  Medical  Sciences. 


Jnler's  Ophthalmic  Science  and  Practice.— New  (2d)  Edition. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  By  HENRY  E. 
JULER,  F.  R.  C.  S.,  Senior  Assistant  Surgeon,  Royal  Westminster  Ophthalmic  Hospital; 
Late  Clinical  Assistant,  Moorfields,  London.  New  (2d)  edition.  Handsome  8vo.  volume 
of  561  pages,  with  201  woodcuts,  17  colored  plates,  selections  from  Test-types  of  Jaeger 
and  Snellen,  and  Holmgren's  Color-blindness  Test.  Cloth,  $5.50 ;  leather,  $6.50. 

The  continuous  approval   manifested   towards  I  matter  of  practical  value.  The  sections  devoted  to 
this  work  testifies  to  the  success  with  which  the    treatment  are  singularly  full,  and  at  the  same  time 
author   has  produced  concise   descriptions   and    concise,  and  couched  in  language  that  cannot  fail 
typical  illustrations  of  all  the  important  affections    to  be  understood.— The  Medical  Age. 
of  the  eye.    The  volume  is  particularly  rich  in 

Nettleship  on  the  Eye.— Fifth  Edition. 

Diseases  of  the  Eye.  By  EDWARD  NETTLESHIP,  F.  R.  C.  S.,  Ophthalmic 
Surgeon  at  St.  Thomas'  Hospital,  London.  Surgeon  to  the  Royal  London  (Moorfields) 
Ophthalmic  Hospital.  Fourth  American  from  the  fifth  English  edition,  thor- 
oughly revised.  With  a  Supplement  on  the  Detection  of  Color  Blindness,  by  WIL- 
LIAM THOMSON,  M.  D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical  College 
Philadelphia.  In  one  12mo.  volume  of  500  pages,  with  164  illustrations,  selections  from 
Snellen's  test-types  and  formulae,  and  a  colored  plate.  Cloth,  $2.00. 

This  is  a  well-known  and  a  valuable  work.    It  I  knowledge  to  be  present  which  seems  to  be  as- 
was  primarily  intended  for  the  use  of  students,  j  sumed  in  some  of  our  larger  works,  is  not  tedious 


»nd  supplies"  their  needs  admirably,  but  it  is  as 


useful  for  the  practitioner,  or  indeed  more  so.    It    important  parts  of  clinical  ophthalmology.— Neu 
does  not  presuppose  the  large  amount  of  recondite     ' 


from  over-conciseness,  and  yet  covers  the  more 


York  Medical  Journal. 


Carter  &  Frost's  Ophthalmic  Surgery. 

Ophthalmic  Surgery.  By  R.  BRUDENELL  CARTER,  F.R.  C.  S.,  Lecturer  on 
Ophthalmic  Surgery  at  St.  George's  Hospital,  London,  and  W.  ADAMS  FROST,  F.  R.  C.  S., 
Joint  Lecturer  on  Ophthalmic  Surgery  at  St.  George's  Hospital,  London.  In  one  12mo. 
volume  of  559  pages,  with  91  woodcuts,  color-blindness  test,  test-types  and  dots  and  appen- 
dix of  formulse.  Cloth,  $2.25.  See  Series  of  Clinical  Manuals,  page  30. 


THOMPSON  ON  THE  URINARY  ORGANS,  j 
Lectures  on  Diseases  of  the  Urinary  Organs. 
By  SIB  HENRY  THOMPSON,  Professor  of  Clinical 
Surgery  in  University  College  Hospital.  London. 
Second  American  from  the  third  English  edition. 
Octavo.  203  pages,  25  illustrations  CJ°'rh'  Ti^ 

THOMPSON  ON  THE  PATHOLOGY  AND 
TREATMENT  OF  STRICTURE  OF  THE 
URETHRA  AND  URINARY  FISTULA. 
From  the  third  English  edition.  In  one  octavo 
volume  of  359  pages,  with  47  engravings  and  3 

BA^HAM  CONh> RENAL  DISEASES:  A  Clinical 
Guide  to  their  Diagnosis  and  Treatment  12mo. 
304  pages,  with  21  Illustrations.  Cloth,  $2.00. 


WELLS  ON  THE  EYE.    In  one  octavo  volume. 

LAURENCE  AND  MOON'S  HANDY  BOOK  OF 
OPHTHALMIC  SURGERY,  for  the  uge  of  Prac- 
titioners. Second  edition.  In  one  octavo  vol- 
ume of  227  pages,  with  66  illus.  Cloth,  $2.76. 

LAWSON  ON  INJURIES  TO  THE  EYE,  ORBIT 
AND  EYELIDS:  Their  Immediate  and  Remote 
Effects.  In  one  octavo  volume  of  404  pages,  with 
92  illustrations.  Cloth,  $3.60. 

MORRIS  ON  SURGICAL  DISEASES  OF  THE 
KIDNEY.  By  HENRY  MORRIS.  F.  R.  C.  S.,  Surgeon 
to  Middlesex  Hospital,  London.  12mo.,  654  pp., 
with  40  woodcuts,  and  6  colored  plates.  Limp 
cloth,  82.26.  See  Series  of  Clinical  Manuals,  p.  30. 


Lia  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


24      Otology,  Urinary  &  Renal  Dis.,  Dentistry. 


Politzer  on  Diseases  of  the  Ear.— Third  Edition. 

A  Text-Book  of  Diseases  of  the  Ear  and  Adjacent  Organs. 
By  DR.  ADAM  POLITZER,  Imperial-Royal  Professor  of  Aural  Therapeutics  in  the  Univer- 
sity of  Vienna,  Chief  of  the  Imperial -Royal  University  Clinic  for  Diseases  of  the  Ear  in 
the  General  Hospital,  Vienna.  Translated  into  English  from  the  third  atd  revised 
German  edition,  by  OSCAR  DODD,  M.  D.,  Clinical  Instructor  in  Diseases  of  the  Eye  and 
Ear,  College  of  Physicians  and  Surgeons,  Chica?o.  Edited  by  SIR  WILLIAM  DALBY, 
F.  R.  C.  S.,  M.  B.,  Consulting  Aural  Surgeon  to  St.  George's  Hospital,  London.  In  one 
large  octavo  volume  of  748  pages,  with  330  illustrations.  Cloth,  $5.50. 

This  edition  of  the  eminent  Vienna  professor's  |  underlie  the  clinical  remarks  and  details  of  meth- 
well-known  work  will  be  welcomed  by  those  who  j  ods  of  treatment.  The  indications  for  treatment 
wish  to  obtain  a  complete  account  of  all  that  is  |  are  clear  and  reliable.  We  can  confidently  rec- 
known  in  connection  with  aural  diseases.  Who-  pmmend  it,  for  it  contains,  as  stated  by  the  editor 
ev«r  peruses  it  carefully  cannot  fail  to  be  struck  in  his  preface,  all  that  is  known  upon  the  subject, 
with  the  details,  the  extensive  references,  and  i  — London  Lancet.  • 
especially  the  valuable  pathological  data,  which 

Field's  Manual  of  Diseases  of  the  Ear. 

A  Manual  of  Diseases  of  the  Ear.  By  GEORGE  P.  FIELD,  M.  R.  C.  S., 
Aural  Surgeon  and  Lecturer  on  Aural  Surgery  in  St  Mary's  Hospital  Medical  School, 
London.  In  one  octavo  of  391  pp.,  with  73  engravings  and  21  colored  plates.  Cloth,  $3.75. 
To  those  who  desire  a  concise  work  on  diseases  ;  large  c'ass  of  cases  of  ear  disease  that  comes 
of  the  ear,  clear  and  practical,  this  manual  com-  <  properly  within  his  province.  The  illustrations 
mends  itself  in  the  highest  degree.  It  is  just  such  are  apt  and  well  executed  while  the  make-up  of 
a  work  as  is  needed  by  every  general  practi-  ;  the  work  is  beyond  criticism. — The  American 
tioner  to  enable  him  to  treat  intelligently  the  Practitioner  and  News. 

Burnett  on  the  Ear.— Second  Edition. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical 
Treatise  for  the  use  of  Medical  Students  and  Practitioners.  By  CHARLES  H.  BURNETT, 
A.M.,  M.  D.,  Professor  of  Otology  in  the  Philadelphia  Polyclinic ;  President  of  the 
American  Otological  Society.  Second  edition.  In  one  handsome  octavo  volume  of  580 
pages,  with  107  illustrations.  Cloth,  $4.00 ;  leather,  $5.00. 

Black  on  the  Urine.— Just  Ready. 

The  Urine  in  Health  and  Disease,  and  Urinary  Analysis,  Physi- 
ologically and  Pathologically  Considered.  By  D.  CAMPBELL  BLACK,  M.  D., 
L.  R.  C.  S.,  Professor  of  Physiology,  Anderson  College  Medical  School.  In  one  12mo. 
volume  of  256  pages,  with  73  engravings.  Cloth,  $2.75. 

Roberts  on  Urinary  and  Renal  Diseases.— Fourth  Edition. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including 
Urinary  Deposits.  By  SIR  WILLIAM  ROBERTS,  M.  D.,  Lecturer  on  Medicine  in  the 
Manchester  School  of  Medicine,  etc.  Fourth  American  from  the  fourth  London  edi- 
tion. In  one  handsome  octavo  volume  of  609  pages,  with  81  illustrations.  Cloth,  $3.50. 

Purdy  on  Bright's  Disease  and  Allied  Affections. 

Bright's  Disease  and  Allied  Affections  of  the  Kidneys.  By 
CHARLES  W.  PURDY,  M.  D.,  Professor  of  Genito-Urinary  and  Renal  Diseases  in  the  Chi- 
cago Polyclinic.  In  one  octavo  vol.  of  288  pages,  with  illustrations.  Cloth,  $2.00. 

The  American  Text-Books  of  Dentistry.— Preparing. 

In  Contributions  by  Various  Authors.  In  two  octavo  volumes  of  about 
600  pages  each,  fully  illustrated.  VOLUME  I.,  OPERATIVE  DENTISTRY.  Edited  by 
EDWARD  C.  KIRK,  D.  D.  S.,  Lecturer  on  Operative  Dentistry,  Dept.  of  Dentistry,  Univ.  of 
Penna.  VOLUME  II.,  MECHANICAL  DENTISTRY.  Edited  by  CHARLES  J.  ESSIG,  M.  D., 
D.D.  S ,  Prof,  of  Mechanical  Dentistry  and  Metallurgy,  Dept.  of  Dentistry,  Univ.  of  Penna. 

The  American  System  of  Dentistry. 

In  Treatises  by  Various  Authors.  Edited  by  WILBUR  F.  LITCH,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  and  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  con- 
taining 3160  pages,  with  1863  illustrations  and  9  full-page  plates.  Per  volume,  cloth,  $6  ; 
leather,  $7  ;  half  Morocco,  gilt  top,  $8.  For  sale  by  subscription  only. 


As  an  encyclopedia  of  Dentistry  it  has  no  su 
perior.  It  should  form  a  part  of  every  dentist's 
library,  as  the  information  it  contains  is  of  the 
greatest  value  to  all  engaged  in  the  practice  of 
dentistry. — American  Journal  of  Dental  Science. 

A  grand  system,  big  enough  and  good  enough 
and  handsome  enough  for  a  monument  (which 


doubtless  it  is),  to  mark  an  epoch  in  the  history  of 
dentistry.  Dentists  will  be  satisfied  with  it  and 
proud  of  it — they  must.  It  is  sure  to  be  precisely 
what  the  student  needs  to  put  him  and  keep  him 
in  the  right  track,  while  the  profession  at  large 
will  receive  incalculable  benefit  from  it. — Odonto- 
graphic  Journal. 


COLEMAN'S  MANUAL  OF  DENTAL  SURGERY 
AND  PATHOLOGY  By  ALFRED  COLEMAN,  L.D.S. 
Thoroughly  revised  and  adapted  to  the  use  of 


American  Students,  by  THOMAS  C.  STELL WAGES, 
D.  D.S.  Octavo,  412  pages,  with  331  illustrations. 
Cloth,  83.25. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Impotence,  Sterility,  Venereal,  Skin.  25 


Gross  on  Impotence,  Sterility,  etc.— Fourth  Edition. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Dis- 
orders of  the  Male  Sexual  Organs.  By  SAMUEL  W.  GROSS,  A.  M.,  M.  D., 
LL.  D.,  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson 
Medical  College  of  Philadelphia.  Fourth  edition,  thoroughly  revised  by  F.  R.  STURGIS, 
M.  D.,  Prof,  of  Diseases  of  the  Genito- Urinary  Organs  and  of  Venereal  Diseases, 
N.  Y.  Post  Grad.  Med.  School.  In  one  8vo.  vol.  of  165  pages,  with  18  illus.  Cloth,  $1.50. 
Three  editions  of  Professor  Gross1  valuable  book  rhcea,  and  prostatorrhcea.  The  book  is  a  practical 
have  been  exhausted,  and  still  the  demand  is  one  and  in  addition  to'  the  scientific  and  very  in- 
unsupplied.  Dr.  Sturgis  has  revised  and  added 
to  the  previous  editions,  and  the  new  one  appears 
more  complete  and  more  valuable  than  before,  practi 
Four  important  and  generally  misunderstood  sub-  success  in  the  hands  of  author  and  editor. — Medi- 
jects  are  treated — impotence,  sterility,  epermator-  cal  Record. 


Fuller  on  Male  Sexual  Disorders.— Shortly. 

Disorders  of  the  Sexual  Organs  in  the  Male.  By  EUGKNE  FULLER, 
M.  D ,  Instructor  in  Venereal  and  Genito-Urinary  Diseases,  New  York  Post-Graduate 
Medical  School.  In  one  very  handsome  octavo  volume  of  about  200  pages,  fully  illustrated. 

Taylor  on  Venereal  Diseases.— Sixth  Edition.   In  Press. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  By  ROBERT  W.  TAYLOR,  A.  M.,  M.  D., 
Clinical  Professor  of  Genito-Urinary  Diseases  in  the  College  of  Physicians  and  Surgeons, 
New  York.  Being  the  sixth  edition  of  Sumstead  and  Taylor,  rewritten  by  Dr.  Taylor. 
Large  8vo.  volume,  about  900  pages,  with  about  150  engravings,  as  well  as  numerous 
chromo-lithographs.  In  active  preparation. 

Culver  &  Hayden's  Manual  of  Venereal  Diseases. 

A  Manual  of  Venereal  Diseases.  By  EVERETT  M.  CULVER,  M.  D., 
Pathologist  and  Assistant  Attend  ing  Surgeon,  Manhattan  Hospital,  New  York,  and  JAMES 
R.  HAYDEN,  M.  D.,  Chief  of  Clinic  Venereal  Department,  College  of  Physicians  and  Sur- 
geons New  York.  In  one  12mo.  volume  of  289  pages,  with  33  illus.  Cloth,  $1.75. 


This  book  is  a  practical  treatise,  presenting  in  a 
condensed  form  the  essential  features  of  our  pres- 
ent knowledge  of  the  three  venereal  diseases, 
syphilis,  chancroid  and  gonorrhea.  We  have  ex- 
amined this  work  carefully  and  have  come  to  the 
conclusion  that  it  is  the  most  concise,  direct  and 
able  treatise  that  has  appeared  on  the  subject  of 


venereal  diseases  for  the  general  practitioner  to 
adopt  as  a  guide.  The  general  practitioner  needs 
a  few  simple,  concise  and  clearly  presented  laws, 
in  the  execution  of  which  he  cannot  fail  either  to 
cure  or  prevent  the  ravages  of  the  maladies  in 
question  and  their  direful  results.— Buffalo  Medical 
and  Surgical  Journal. 


Cornil  on  Syphilis. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.    By  V. 

CORNIL,  Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lourcme  Hos- 
pital. Specially  revised  by  the  Author,  and  translated  with  notes  and  additions  by  J. 
HENRY  C.  SIMES,  M.  D.,  Demonstrator  of  Pathological  Histology  in  the  Umv.  of  Fa., 
and  J.  WILLIAM  WHITE,  M.  D.,  Lecturer  on  Venereal  Diseases,  Univ.  of  Pa.  In  one 
handsome  octavo  volume  of  461  pages,  with  84  very  beautiful  illustrations.  <  >th,  $3./5. 

Hutchinson  on  Syphilis. 

Syphilis.  Bv  JONATHAN  HUTCHINSON,  F.  R.  S.,  F.  R.  C.  S.,  Consulting  Sur- 
geon to  the  London  Hospital.  In  one  12mo.  volume  of  542  pages,  with  8  chromo- 
lithographs. Cloth,  $2.25.  See  Series  of  Clinical  Manuals,  page  30. 

Hardaway's  Manual  of  Skin  Diseases. 

Manual  of  Skin  Diseases.  With  Special  Reference  to  Diagnosis  and  Treat- 
ment. F^tlTe  use  of  Students  and  General  Practitioners.  By  W.  A^ARDAW  AY,  M.  D 


^^  ^o^sSt^Tp^t^^ 

AR      BLADDER,  THF  PROS-  can  edition.    In  one  12mo.  rolume  of  353  page*, 

TE  GiD  VD°  LTI?D  S&™  \^l  *$t3$&*$SS&  8£  LOCAL  CONTAGIOUS 

&?hoG^ 

M.D.    Inoneoctavo  volume  of  574  pages,  with  LtH   11  un^    DISEASE    AFFECTING 

larged     In  one  12mo.  vol.  of  238  pp.    Cloth,  81.25. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street.  Philadelphia. 


26  Venereal  and  Skin  Diseases. 

Hyde  on  the  Skin.— Third  Edition. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students 
and  Practitioners.  By  J.  NEVIXS  HYDE,  A.  M.,  M.  D.,  Professor  of  Dermatology  and  Ven- 
ereal Diseases  in  Rush  Medical  College,  Chicago.  Third  edition.  In  one  octavo  volume 
of  802  pages,  with  9  colored  plates  and  108  engravings.  Cloth,  $5.00;  leather,  $6.00. 

The  third  edition,  just  issued,  fulfils  all  the  ex-  j  for  information  as  to  how  to  manage  his  patients 
pectations  warranted  by  the  great  accumulation  I  with  skin  diseases.  The  present  edition  may  be 
of  dermatological  material  since  the  earlier  I  commended  as  being  an  exposition  of  the  subject 
editions  were  brought  out,  and  puts  this  work  at  fully  up  to  the  present  state  of  our  knowledge, 
the  head  of  the  modern  American  treatises  on  \-TheChicago  Clinical  Review. 
skin  diseases.  The  author  has  introduced  thirty-  1  Dr.  Hyde's  book  may  be  heartily  commended 
five  new  diseases  in  this  edition.  He  is  especially  '<  to  the  student  and  practitioner  alike  as  one  of  the 
to  be  congratulated  on  his  chapter  on  tuberculosis,  best  exponents  of  the  subject  now  before  the  pro- 
Five  plates  and  twenty- two  woodcuts,  all  of  great  :  tension.— The  American  Journal  of  the  Meaual 
excellence,  have  been  added  to  the  illustrations.  Sciences. 

Dr.  Hyde  is  an  experienced  scholar  as  well  as  a 


The  excellence  of  the  chapters  on  treatment,  to- 
gether with  the  care  that  has  been  bestowed  on 
subjects  that  have  acquired  new  interest,  make 
the  book  one  to  be  warmly  recommended. — Bos- 
ton Medical  and  Surgiral  Journal. 

The  qualities  that  have  contributed  so  much  to 
its  previous  popularity  still  remain.  The  chief  of 
these  unquestionably  are  the  standpoint  of  prac- 
tical medicine  from  which  it  speaks  and  its  wealth 
of  therapeutical  information.  The  writer  knows 
no  book  in  which  one  can  seek  more  satisfactorily 


competent  author,  and  his  former  editions  were 
received  with  approval  by  dermatologists  as  well 
as  by  those  general  practitioners  who  are  inter- 
ested in  the  study  and  treatment  of  diseases  of 
the  skin.  The  treatise  is  one  that  affords  much 
satisfaction  in  that  it  is  a  safe  guide  for  both  stu- 
dents and  practitioners,  either  general  or  special, 
and  particularly  does  it  adapt  itself  to  the  use  of 
dermatologists.— Buffalo  Medical  and  Surgical  Jour- 
nal. 


Taylor's  Clinical  Atlas  of  Venereal  and  Skin  Diseases. 

A  Clinical  Atlas  of  Venereal  and  Skin  Diseases:  Including  Diag- 
nosis, Prognosis  and  Treatment.  By  ROBERT  W.  TAYLOR,  A.  M.,  M.  D.,  Clinical  Pro- 
fessor of  Genito-Urinary  Diseases  in  the  College  of  Physicians  and  Surgeons,  New  York ; 
In  eight  large  folio  parts,  and  comprising  58  beautifully  colored  plates  with  213  figures, 
and  431  pages  of  text  with  85  engravings.  Price  per  part,  $2.50.  Bound  in  one  volume, 
half  Russia,  $27  ;  half  Turkey  Morocco,  $28.  For  sale  by  subscription  only.  Specimen 
plates  sent  on  receipt  of  10  cents.  A  full  prospectus  sent  to  any  address  on  application. 

Jackson's  Ready-Reference  Handbook  of  Skin  Diseases. 

The  Beady-Reference  Handbook  of  Diseases  of  the  Skin.  By 
GEORGE  THOMAS  JACKSON,  M.  D.,  Professor  of  Dermatology,  Woman's  Medical  College 
of  the  New  York  Infirmary.  In  one  12mo.  volume  of  544  pages,  with  50  illustrations 
and  a  colored  plate.  Cloth,  $2.75. 

ment."   It  treats  in  alphabetical  order  of  the  dis- 
eases of  the  skin  and  their  management.     This 


Intended  to  serve  as  a  reference  book  for  the 
general  practitioner,  "no  attempt  has  been  made 
to  discuss  debatable  questions,"  and  "hence  pa- 
thology and  etiology  do  not  receive  as  full  consid- 
eration as  symptomatology,  diagnosis  and  treat- 


book  seems  to  us  the  best  of  its  class  that  has 
yet  appeared. — Boston  Medical  and  Surgical  Jour- 
na/J 


Morris  on  the  Skin.— Just  Ready. 

Diseases  of  the  Skin.  An  Outline  of  the  Principles  and  Practice  of  Der- 
matology. By  MALCOLM  MORRIS,  F.  R.  C.  S.,  Surgeon  to  the  Skin  Department,  St.  Mary's 
Hospital,  London.  In  one  square  octavo  volume  of  565  pages,  with  19  chromo-lithographic 
figures  and  17  engravings.  Cloth,  $3.50. 

The  present  work  is  entirely  new  and  is  place  within  the  intelligent  command  of  the 
•designed  to  be  essentially  clinical  and  practical  ,  reader  the  very  full  recommendations  as  to 
in  scope.  Diagnosis,  symptoms,  causation  and  treatment.  Every  part  of  the  book  represents  the 
prognosis  receive  sufficient  space  to  convey  a  !  most  modern  knowledge  and  methods. — Pacific 
clear  idea  of  the  nature  of  each  disease,  and  to  \  Medical  Journal,  May,  1895. 

Pye-Smith  on  Diseases  of  the  Skin. 

A  Handbook  of  Diseases  of  the  Skin.  By  P.  H.  PYE-SMITH,  M.  D., 
F.  R.  S  ,  Physician  to  Guy's  Hospital,  London.  In  one  octavo  volume  of  407  pages, 
with  26  illustrations,  23  of  which  are  colored.  Cloth,  $2.00. 

The  book  is  an  excellent  one,  and  we  commend  known  as  one  of  the  eminent  physicians  to  Guy's 
it  to  all  interested  in  the  subject.  It  is  written  by  Hospital,  and  we  have  no  hesitation  in  saying 
one  entirely  familiar  with  skin  diseases,  both  that  he  has  written  an  original  and  valuable 
from  the  standpoint  of  the  specialist  and  the  handbook  on  skin  diseases,  sound  and  practical 
general  practitioner.  Dr.  Pye-Smith  is  favorably  ;  in  all  its  bearings. — International  Med.  Magazine. 

Jamieson  on  Diseases  of  the  Skin.— Third  Edition. 

Diseases  of  the  Skin.  A  Manual  for  Students  and  Practitioners.  By 
W.  ALLAN  JAMIESON,  M.  D.,  Lecturer  on  Diseases  of  the  Skin,  School  of  Medicine,  Edin- 
burgh. Third  edition,  revised  and  enlarged.  In  one  octavo  volume  of  656  pages,  with 
woodcut  and  9  double-page  chromo-lithographic  illustrations.  Cloth,  $6.00. 


The  scope  of  the  work  is  essentially  clinical,  lit- 
tle reference  being  made  to  pathology  or  disputed 
theories.  Almost  every  subject  is  followed  by 
illustrative  cases.  The  pages  are  filled  with  inter- 
est to  all  those  occupied  with  skin  diseases.  The 


general  practitioner  will  find  the  book  of  great 
value  in  matters  of  diagnosis  and  treatment.  The 
latter  is  quite  up  to  date,  and  the  formulae  have 
been  selected  with  care. — Medical  Record. 


WILSON'S  STUDENT'S  BOOK  OF  CUTANEOUS    I    In  one  handsome  small  octavo  volume  of  635 
MEDICINE  AND  DISEASES  OF  THE  SKIN.    |    pages.    Cloth,  $3.50. 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Diseases  of  Women. 


27 


The  American  Systems  of  Gynecology  and  Obstetrics. 

Systems  of  Gynecology  and  Obstetrics,  in  Treatises  by  American 
Authors.  Gynecology  edited  by  MATTHEW  D.  MANN,  A.  M.,  M.  D.,  Professor  of  Obstetrics 
and  Gynecology  in  the  Medical  Department  of  the  University  of  Buffalo;  and  Obstet- 
rics edited  by  BARTON  COOKE  HIRST,  M.  D.,  Associate  Professor  of  Obstetrics  in  the 
University  of  Pennsylvania,  Philadelphia.  In  four  very  handsome  octavo  volumes,  con- 
taining 3612  pages,  1092  engravings  and  8  plates.  Complete  work  now  ready.  Per  vol- 
ume: Cloth,  $5.00;  leather,  $6.00;  half  Russia,  $7.00.  For  sale  by  subscription  only. 
Address  the  Publishers.  Full  descriptive  circular  free  on  application. 


fession  in  this  country  can  feel  proud.  Written  well  informed  in  regard  to  the  peculiarities  of 
exclusively  by  American  physicians  who  are  ae-  American  women,  their  manners,  customs,  modes 
quainted  with  all  the  varieties  of  climate  in  the  of  living,  etc.  As  every  practising  physician  is 
United  States,  the  character  of  the  soil,  the  man-  called  upon  to  treat  diseases  of  females,  and  as 
ners  and  customs  of  the  people,  etc.,  it  is  pecul-  they  constitute  a  class  to  which  the  family  phy- 
iarly  adapted  to  the  wants  of  American  practition-  j  sician  must  give  attention,  and  cannot  pass  over 


ers  of  medicine,  and  it  seems  to  us  that  every  one 
of  them  would  desire  to  have  it."  Every  word 
thus  expressed  in  regard  to  the  "American  Sys- 
tem of  Practical  Medicine"  is  applicable  to  the 
"System  of  Gynecology  by  American  Authors." 


to  a  specialist,  we  dp  not  know  of  a  work  in  any 
department  of  medicine  that  we  should  so  strongly 
recommend  medical  men  generally  purchasing.— 
Cincinnati  Med.  News. 


Emmet's  Gynaecology.— Third  Edition. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students 
and  Practitioners  of  Medicine.  By  THOMAS  ADDIS  EMMET,  M.  D.,  LL.  D.,  Surgeon  to 
the  Woman's  Hospital,  New  York,  etc.  Third  edition,  thoroughly  revised.  In  one 
large  and  very  handsome  8vo.  vol.  of  880  pp.,  with  150  illus.  Cloth,  $5 ;  leather,  $6. 
We  are  in  doubt  whether  to  congratulate  the  I  the  privilege  thus  offered  them  of  perusing  the 

views  and  practice  of  the  author.   His  earnestness 


author  more  than  the  profession  upon  the  appear- 
ance of  the  third  edition  of  this  well-known  work. 
Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  conspicuously  distinguished  himself 
as  a  bold  and  successful  operator,  and  who  has 
devoted  so  much  attention  to  the  specialty,  we 
feel  sure  the  profession  will  not  fail  to  appreciate 


of  purpose  and  conscientiousness  are  manifest. 
He  gives  not  only  his  individual  experience  but 
endeavors  to  represent  the  actual  state  of  gynse- 
cological  science  and  art. — British  Medical  Jour- 
nal. 


Tait's  Diseases  of  Women  and  Abdominal  Surgery. 

Diseases  of  Women  and  Abdominal  Surgery.    By  LAWSON  TAIT, 
F.E.  C.  S.,  Professor  of  Gynaecology  in  Queen's  College,  Birmingham,  late  President  of 
the  British  Gynecological  Society,  Fellow  American  Gynaecological  Society.     In  two 
octavo  vols.    Vol.  I.,  554  pp.,  62  engravings  and  3  plates.    Cloth,  $3.    Vol.  II.,  preparing. 
Mr.  Tait  never  writes  anything  that  does   not    on  the  technique  of  surgical  operations,  ingenious 
command  attention  by  reason  of  the  originality  of    theories  on  pathology,  daring  innovations  on  long- 
his  ideas  and  the  clear  and  forcible  manner  in    established    lines— these   succeed   one    anothe 
which  they  are   expressed.    This  is    eminently    with  a  bewildering   rapidity.    His  position   has 
true  of  the  present   work.    Germs  of  truth  are    long  been  assured.    We  cannot  repress  our  adml- 
thickly    scattered    throughout;    single    happily    ration  for  the  restless  genius  of  the  great  s 
worded  sentences  express  what  another  author    geon.— American  Journal  of  the  Medical  bcunces. 
would  have  expanded  into  pages.    Useful  hints 


Edis  on  Diseases  of  Women. 


The  Diseases  of  Women.  Including  their  Pathology,  Causation,  Symptoms, 
Diagnosis  and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  ARTHUR  W. 
EDIS  M.  D.,  Lond.,  F.  K.  C.  P.,  M.  E.C.S.,  Assistant  Obstetric  Physician  to  Middlesex 
Hospital,  late  Physician  to  British  Lying-in-Hospital.  In  one  handsome  octavo  volume 
of  576  pages,  with  148  illustrations.  Cloth,  $3.00 ;  leather,  $4.00. 

The  special  qualities   which    are   conspicuous  j  among    the  more   common    methods   of 
are  thoroughness  in  covering  the  whole  ground,  I  •»«"* 
clearness  of  description  and  conciseness  of  state- 
ment.     Another  marked  feature  of  the  book  is 
the  attention  paid  to  the  details  of  many  minor 
surgical     operations     and     procedures,     as,    for 


instance,  the  use  of  tents,  application  of  leeches, 
and   use   of    hot   water   injections.      These   are 


till  HI  UK      me    niuio    v » >ui  iuvs«     I^I^VAIW        «••      »« 

ment  and  yet  very  little  is  said  about  them  in 
many  of  the  text-books.  The  book  is  one  to  be 
warmly  recommended  especially  to  students  and 
general  practitioners,  who  need  a  concise  but  com- 
plete rfouwW"  of  the  whole  subject.  Specialists,  too, 


will  find  many  useful  hints  in  its  pages.— Boston 
Medical  and  Surgical  Journal. 


Duncan  on  Diseases  of  Women. 

Clinical  Lectures  on  the  Diseases  of  Women ; 
Bartholomew's  Hospital.    By  J.  MATTHEWS  DUNCAN,  M.  D.,   LL. 
In  one  octavo  volume  of  175  pages.    Cloth^$1.50. 

HODGE  ON  DISEASES  PECULIAR  TO  WOMEN. 
Including  Displacements  of  the  Uterus.  Second 
edition,  revised  and  enlarged.  In  one  beauti- 
fully printed  octavo  volume  of  519  pages,  witn 
original  illustrations.  Cloth,  $4.60. 


etc. 


WKSTS   i,]-:crrri:i-s  <>N  THK  IMSKASF.S  OK 

WOMEN  Third  American  from  the  third  Lon- 
don edition.  In  one  octavo  volume  of  543  pages. 
Cloth,  $3.75;  leather,  $4.75. 


Lea  Brothers  &  Co..  Publishers,  706,708  &  710  Sansom  Street,  Philadelphia. 


28 


Diseases  of  Women — (Continued). 


Thomas  &  Munde  on  Diseases  of  Women.— Sixth  Edition. 

A  Practical  Treatise  on  the  Diseases  of  Women.  By  T.GAILLARD 
THOMAS,  M.  D.,  LL.  D.,  Emeritus  Professor  of  Diseases  of  Women  in  the  College  of 
Physicians  and  Surgeons,  New  York,  and  PAUL  F.  MUNDE,  M.  D.,  Professor  of  Gynecol 
ogy  in  the  New  York  Polyclinic.  Sixth  edition,  thoroughly  revised  and  rewritten 
by  DR.  MUNDE.  In  one  large  and  handsome  octavo  volume  of  824  pages,  with  347 
illustrations,  of  which  201  are  new.  Cloth,  $5.00 ;  leather,  $6.00. 


The  profession  has  sadly  felt  the  want  of  a  text- 
book on  diseases  of  women,  which  should  be  com- 
prehensive and  at  the  same  time  not  diffuse, 
systematically  arranged  so  as  to  be  easily  grasped 
by  the  student  of  limited  experience,  and  which 
should  embrace  the  wonderful  advances  which 


book  we  know,  and  will  be  of  especial  value  to  the 
general  practitioner  as  well  as  to  the  specialist. 
The  illustrations  are  very  satisfactory.— Boston 
Medic. al  and  Surgical  Journal. 

This  work,  which  has  already  gone  through  five 
large    editions,    and    has   been    translated    into 


hare  been  made  within  the  last  two  decades.  I  French,  German,  Spanish  and  Italian,  is  too  well 
Dr.  Munde  brings  to  his  work  a  most  practical  j  known  to  require  commendation.  It  continues  to 
knowledge  of  the  subjects  of  which  he  treats  and  j  be  the  most  practical  and  at  the  same  time  the 
an  exceptional  acquaintance  with  the  world's  liter-  |  most  complete  treatise  upon  the  subject  in  print, 
ature  of  this  important  branch  of  medicine.  The  the  changes  that  have  been  made  only  increasing 
result  is  what  is,  perhaps,  on  the  whole,  the  best  its  value. — The  Archives  of  Gyne'ohgy,  Obstetrics 
practical  treatise  on  the  subject  in  the  English  and  Pediatrics. 
language.  It  is,  as  we  have  said,  the  best  text- ' 

Button  on  Tnmors,  Innocent  and  Malignant. 

Tumors,  Innocent  and  Malignant.  Their  Clinical  Features  and  Ap- 
propriate Treatment.  By  J.  BLAND  SUTTON,  F.  K.  C.  S.,  Assistant  Surgeon  to  the  Mid- 
dlesex Hospital,  London.  In  one  very  handsome  octavo  volume  of  526  pages,  with  250 
engravings  and  9  full  page  plates.  Cloth,  $4.50. 

Button  has  without  doubt  written  the  best  I  many  years  of  research  upon  a  subject  embracing 
general  work  on  tumors  which  has  yet  appeared  ;  some  of  the  commonest,  most  painful  and  hitherto 
in  the  English  language.  We  urge  all  of  our  hopeless  of  human  affections.  As  this  work  deals 
readers  to  get  this  splendid  book. — The  St.  Louis  ;  exhaustively  with  tumors  it  will  furnish  the 
Medical  and  Surgical  Journal.  surgeon,  gynecologist  and  general  practitioner 

The  author  is  widely  known  as  one  of  the  fore-  i  with  indispensable  aid  in  the  early  recognition 
most  surgeons  and  pathologists  of  London.    His    and  successful  treatment  of  this  class  of  disease, 
ability  has  already  been  recognized  in  his  earlier    — The  Omaha  C/irtic. 
works.    In  the  present    instance   he    has    spent 

Sntton  on  the  Ovaries  and  Fallopian  Tubes. 

Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes,  including 
Tubal  Pregnancy.  By  J.  BLAND  SUTTON,  F.  K.  C.  S.,  Assistant  Surgeon  to  the 
Middlesex  Hospital,  London.  In  one  square  octavo  volume  of  544  pages,  with  119 
engravings  and  5  colored  plates.  Cloth,  $3.00. 


This  is  not  a  book  to  be  read  and  then  shelved  ; 
it  is  one  to  be  studied.  It  is  not  based  upon 
hypotheses  but  upon  facts.  It  makes  pathology 
practical,  and  inculcates  a  practice  based  upon 
pathology.  It  is  succinct,  yet  thorough;  practi- 
cal, yet  scientific;  conservative,  yet  bold.  It  is 


is  not  for  them  alone;  the  general  practitioner 
needs  just  such  a  book.  It  will  be  of  immense 
service  to  him  in  the  study  of  pelvic  diseases,  and 
will  assuredly  open  his  eyes  to  the  progress  made 
by  conscientious,  painstaking  workers  like  Dr. 
Sutton  in  the  field  of  pathology  and  differential 


probably  on  the  table  of  all  gynecologists;  but  it  I  diagnosis. — International   Medical  Magazine. 

Davenport's  Non-Surgical  Gynaecology.— Second  Edition. 

Diseases  of  Women,  a  Manual  of  Non-Surgical   Gynaecology. 

Designed  especially  for  the  Use  of  Students  and  General  Practitioners.  By  FRANCIS 
H.  DAVENPORT,  M.  D.,  Assistant  in  Gynaecology  in  the  Medical  Department  of  Harvard 
University.  Second  edition.  In  one  12mo.  vol.  of  314  pages,  with  107  illus.  Cloth,  $1.75. 


Many  valuable  volumes  already  exist  on  the 
surgical  aspects  of  gynecology,  but  scant  attention 
has  been  paid  in  recent  years  to  the  non-surgical 


the  actual  test  of  experience,  and  being  concisely 
and  clearly  written,  conveys  a  great  amount  of  in- 
formation in  a  convenient  space. — Annalsof  Qynoi- 


treatment   of  women's    diseases.     The   present    cology  and  P&diatry. 
volume,  dealing  with  nothing  which  has  not  stood 

May's  Manual  of  Diseases  of  Women.— Second  Edition. 

A  Manual  of  theDiseases  of  Women.  Being  a  concise  and  systematic 
exposition  of  the  theory  and  practice  of  gynecology.  By  CHARLES  H.  MAY,  M.  D., 
late  House  Surgeon  to  Mount  Sinai  Hospital,  New  York.  Second  edition;  edited  by 
L.  S.  EAU,  M.  D.,  Attending  Gynecologist  at  the  Harlem  Hospital,  N.  Y.  In  one  12mo. 
volume  of  360  pages,  with  31  illustrations.  Cloth,  $1.75. 
This  is  a  manual  of  gynecology  in  a  very  con- 


densed form,  and  the  fact  that  a  second  edition 
has  been  called  for  indicates  that  it  has  met  with 
a  favorable  reception.  It  is  intended,  the  author 
tells  us,  to  aid  the  student  who  after  having  care- 
fully perused  larger  works  desires  to  review  the 
subject,  and  he  adds  that  it  may  be  useful  to  the 
practitioner  who  wishes  to  refresh  his  memory 


rapidly  but  has  not  the  time  to  consult  larger 
works.  We  are  much  struck  with  the  readiness 
and  convenience  with  which  one  can  refer  to  any 
subject  contained  in  this  volume.  Carefully  com- 
piled indexes  and  ample  illustrations  also  enrich 
the  work.  This  manual  will  be  found  to  fulfil  its 
purposes  very  satisfactorily. — The  Physician  and 
Surgeon. 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE 
DISEASES   PECULIAR    TO    WOMEN.     Third 


American  from  the  third  and  revised  London 
edition.    In  one  8vo.  vol.,  pp.  520.    Cloth,  $3.50. 


Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Sireet,  Philadelphia. 


Obstetrics.  29 

Playfair's  Midwifery.— New  (8th)  Edition.    Just  Ready. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.    By  W.  S. 

PLAYFAIR,  M.  D.,  F.  K,  C.  P.,  Professor  of  Obstetric  Medicine  in  King's  College,  Lon- 
don, Examiner  in  Midwifery  in  the  Universities  of  Cambridge  and  London,  and  to  the 
Koyal  College  of  Physicians.  Sixth  American,  from  the  eighth  English  edition.  Edited, 
with  additions,  by  ROBERT  P.  HARRIS,  M.  D.  In  one  handsome  octavo  volume  of  697 
pages,  with  217  engravings  and  5  plates.  Cloth,  $4.00 ;  leather,  $5.00. 


This  work  has  long  occupied  a  prominent  posi- 
tion both  as  a  text-book  and  book  of  reference  in 
this  country  and  in  England.  Numerous  students 
have  gleaned  valuable  suggestions  from  its  pages, 
and  its  practical  character  and  the  author's  ability 
for  clear  and  concise  writing  are  well  known. 
Taking  a  broad  view  of  the  work,  it  must  certainly 
be  termed  an  admirable  book.—  The  American 
Journal  of  Obstetrics,  February,  1894. 

This  well-known  treatise  has  been  either  a  text- 
book or  work  of  reference  in  most  medical  schools 
for  the  past  seventeen  years,  and  in  the  numerous 
editions  which  have  appeared  it  has  been  kept 
constantly  in  the  foremost  rank  of  the  books  which 
have  been  written  on  this  subject,  and  is  a  work 
which  can  be  conscientiously  recommended  to  the 
profession.—  The  Albany  Med.  Annals,  March,  1894. 

Since  1877  Playfair  has  been  accepted  as  author- 
ity in  the  department  of  obstetrics.  When  his 
first  edition  was  issued  it  was  found  to  be  such  a 
clear  exposition  of  the  subject  that  Playfair's 


treatise  was  readily  adopted  by  our  colleges  as  a 
text-book.  Students  therefore  became  familiar 
with  it  at  once,  and  obstetricians  have  followed 
it  through  its  several  editions  with  interest  and 
satisfaction.  This  work  of  Playfair  must  occupy 
a  foremost  place  in  obstetric  medicine  as  a  safe 
guide  to  both  student  and  obstetrician.  It  holds 
a  place  among  the  ablest  English  speaking  author- 
ities on  the  obstetric  art. — Buffalo  Medical  and 
Surgical  Journal,  March,  1894. 

The  author's  object  has  been  to  place  in  the 
hands  of  his  readers  an  epitome  of  the  science 
and  practice  of  midwifery,  which  embodies  all 
recent  advances,  and  especially  to  dwell  on  the 
practical  part  of  the  subject,  so  as  to  make  his 
books  a  reliable  guide  to  the  doctor  in  the  practice 
of  this  most  important  and  responsible  branch  of 
medicine.  Th*  demand  for  this  eighth  edition  of 
the  work  testifies  to  the  success  with  which  the 
author  has  executed  his  purpose. —  The  Medical 
Fortnight! >;,  July,  1894. 


Parvin's  Science  and  Art  of  Obstetrics.—  New  (3d)  Edition. 

The  Science  and  Art  of  Obstetrics.  By  THEOPHILITS  PARVIN,  M.  D., 
LL.  D.,  Professor  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  Jefferson 
Medical  College,  Philadelphia.  New  (third)  edition.  In  one  handsome  8vo.  volume  of 
about  700  pages,  with  about  250  engravings  and  a  colored  plate.  In  press. 

King's  Manual  of  Obstetrics.—  New  (6th)  Edition.    In  Press. 

A  Manual  of  Obstetrics.  By  A.  F.  A.  KING,  M.  D.,  Professor  of  Obstetrics 
and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  University,  Wash- 
ington, D.  C.,  and  in  the  University  of  Vermont,  etc.  New  (sixth)  edition.  In  one  12mo. 
volume  of  about  475  pages,  with  about  175  illustrations. 

A  notice  of  the  previous  edition  is  appended. 

So  comprehensive  a  treatise  could  not  be  brought  ;  unnecessary  ornamentation.  Therefore  we  say 
within  the  limits  of  a  book  of  this  size  were  not  '<  there  are  nine  hundred  pages  of  matter  between 
two  things  especially  true.  First,  Dr.  King  is  a  ,  the  covers  of  this  manual  of  four  hundred  and 
teacher  of  many  years'  experience,  and  knows  !  fifty  pages.  We  cannot  imagine  a  better  manual 
just  how  to  present  his  subjects  in  a  manner  for  |  for  the  hard-  worked  student;  while  its  clear  and 
them  to  be  best  received;  and,  secondly,  he  can  i  practical  teachings  make  it  invaluable  to  the  busy 
put  his  ideas  in  a  clear  and  concise  form.  In  practitioner.  The  illustrations  add  much  to  the 
other  words,  he  knows  how  to  use  the  English  i  subject  matter.—  The  Rational  Medical  Review. 
language.  He  gives  us  the  plain  truth,  free  from 

Barnes'  System  of  Obstetric  Medicine  and  Surgery. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and 
Clinical.  For  the  Student  and  the  Practitioner.  By  ROBERT  BARNES,  M.  D.,  Phys- 
ician to  the  General  Lying-in  Hospital,  London,  and  FANCOURT  BARNES,  M.  D.,  Obstetric 
Physician  to  St.  Thomas'  Hospital,  London.  The  Section  on  Embryology  by  Prof.  Milnes 
Marshall.  In  one  8vo.  volume  of  872  pp.,  with  231  illustrations.  Cloth,  $5  ;  leather,  $b. 

Davis'  Obstetrics.—  Preparing. 

A  Treatise  on  Obstetrics.  For  Students  and  Practitioners.  By  EDWARD 
P  DAVIS  A.  M.,  M.  D.,  Professor  of  Obstetrics  and  Diseases  of  Infancy  in  the  Philadel- 
phia Polyclinic,  Clinical  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  of 
Philadelphia.  In  one  very  handsome  octavo  volume  of  500  pages,  richly  illustrated. 

Landis  on  Labor  and  the  Lying-in  Period. 

The  Management  of  Labor,  and  of  the  Lying-m  Period. 
By  HENRY  G.  LANDIS,  A.  M.,  M.  D.,  Professor  of  Obstetrics  and  the  Diseases  of  Wonwn 
in  Starling  Medical  College,  Columbus,  Ohio.  In  one  handsome  12mo.  volume  of  A64 
pages,  with  28  illustrations.  Cloth,  $1.75. 


TcoosTBTMDICE 

SURGERY.    SHOES*  iSHZffB  pages,  !      MEN.    In  oneSvo  TO! 
with  64  full  page  plates  and  43  woodcuts  ,n  the    ^^^ 

TANNBROM  [PREGNANCY.     Octavo,  490  pages,       AND  THE  PUERPERAL  STATE.    Octavo. 
colored  plates,  16  cuts.    Cloth,  84.25  __  I 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


30      Dis.  of  Children,  Obstetrics — (Cont'd),  Manuals. 
Smith  on  Children.— Seventh  Edition. 

A  Treatise   on   the    Diseases   of  Infancy    and    Childhood.    By 

J.  LEWIS  SMITH,  M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital 
Medical  College,  New  York.  New  (seventh)  edition,  thoroughly  revised  and  rewritten. 
In  one  handsome  octavo  volume  of  881  pages,  with  51  illus.  Cloth,  $4.50 ;  leather,  $5.50. 
We  have  always  considered  Dr.  Smith's  book  as  j  is  always  conservative  and  thorough,  and  the 
one  of  the  very  best  on  the  subject.  It  has  always  evidence  of  research  has  long  since  placed  its 
been  practical— a  field  book,  theoretical  where  author  in  the  front  rank  of  medical  teachers. — 
theory  has  been  deduced  from  practical  experi-  j  The  American  Journal  of  the  Medical  Sciences. 
ence.  He  takes  his  theory  from  the  bedside  and  I  In  the  present  edition  we  notice  that  many  of 
the  pathological  laboratory.  The  very  practical  j  the  chapters  have  been  entirely  rewritten.  Full 
character  of  this  book  has  always  appealed  to  us.  notice  is  taken  of  all  the  recent  advances  that 
It  is  characteristic  of  Dr.  Smith  in  all  his  writings  j  have  been  made.  Many  diseases  not  previously 

treated  of  have  received  special  chapters.     The 
work  is  a  very  practical  one.      Especial  care  has 


to  collect  whatever  recommendations  are  found  in 
medical  literature,  and  his  search  has  been  wide. 
One  seldom  fails  to  find  here  a  practical  suggestion 
after  search  in  other  works  has  been  in  vain.  In 
the  seventh  edition  we  note  a  variety  of  changes 
in  accordance  with  the  progress  of  the  times.  It 
still  stands  foremost  as  ihe  American  text-book. 
The  literary  style  could  not  be  excelled,  its  advice 


been  taken  that  the  directions  for  treatment  shall 
be  particular  and  full.  In  no  other  work  are  such 
careful  instructions  given  in  the  details  of  infant 
hygiene  and  the  artificial  feeding  of  infants. — 
Montreal  Medical  Journal. 


Herman's  First  Lines  in  Midwifery. 

First  Lines  in  Midwifery:  a  Guide  to  Attendance  on  Natural 
Labor  for  Medical  Students  and  Midwives.  By  G.  ERNEST  HERMAN,  M.  B., 
F.  E.  C.  P.,  Obstetric  Physician  to  the  London  Hospital.  In  one  12ino.  volume  of  198 
pages,  with  SO^llustrations.  Cloth,  $1.25.  See  Studtnfs  Series  of  Manuals,  below. 

This  is  a  little  book,  intended  for  the  medical  will  prove  valuable  to  the  beginner  in  midwifery 
student  and  the  educated  midwife.  The  work  and  could  be  read  with  advantage  by  the  majority 
is  written  in  a  plain,  simple  style,  and  is  as  of  practitioners,  old  and  young. — The  Medical 
much  as  possible  devoid  of  technical  terms.  It  Fortnightly. 

Owen  on  Surgical  Diseases  of  Children. 

Surgical  Diseases  of  Children.  By  EDMUND  OWEN,  M.  B.,  F.  E.  C.  S., 
Surgeon  to  the  Children's  Hospital,  Great  Ormond  Street,  London.  In  one  12mo.  vol- 
ume of  525  pages,  with  4  chrome-lithographic  plates  and  85  woodcuts.  Cloth,  $2.00. 
See  Series  of  Clinical  Manuals,  below. 

Student's  Series  of  Manuals. 

ASeriesof  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine  and  Surgery, 
written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size  12mo.  volumes  of  300-540  pages. 


Diagnosis,  82;  ROBEBTSON  s  Physiological  Physics,  $2 ;  BBCCE'S  'Materia  Medica  and  Therapeutics  (5th  edi- 
tion), $1.50;  POWEK'S  Human  Physiology  (2d  edition),  81.50;    CLAEKE  and  LOCKWOOD'S  Dissectors'  Man- 
ual, $1.50;  RALFE'S  Clinical  Chemistry,  $1.50;   TBEVES'  Surgical  Applied  Anatomy,  $2;   PEPPER'S  Surgical 
Pathology,  $2;  and  KLEIN'S  Elements  of  Histology  (4th  edition),  $1.75.     The  following  is  in  press 
PEPPER'S  Forensic  Medicine.    For  separate  notices  see  index  on  last  page. 

Series  of  Clinical  Manuals. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the  profession  with 
a  collection  of  authoritative  monographs  on  important  clinical  subjects  in  a  cheap  and  portable  form. 
The  volumes  contain  about  550  pages  and  are  freely  illustrated  by  chromo-lithographs  and  wood- 
cuts. The  following  volumes  are  now  ready:  BALL  on  the  Rectum  and  Anus,  second  edition,  $2.25; 
YEO  on  Food  in  Health  and  Disease,  $2;  BBOADBENT  on  the  Pulse,  $1.75;  CABTEK  A  FBOST'S  Ophthalmic 
Surgery,  $2.25 ;  HXJTCHINSON  on  Syphilis,  $2.25;  MABSH  on  the  Joints,  $2;  OWEN  on  Surgical  Diseases 
of  Children,  $2;  MORRIS  on  Surgical  Disuses  of  the  Kidney,  $2.25;  PICK  on  Fractures  and  Disloca- 
tions, $2;  BUTLIN  on  the  Tongue,  $3.50;  TBEVES  on  Intestinal  Obstruction,  $2;  and  SAVAGE  on  Insanity 
and  Allied  Neuroses,  $2.  The  following  is  in  preparation:  LUCAS  on  Diseases  of  the  Urethra.  For  sepa- 
rate notices  see  index  on  last  page. 

Hartshorne's  Conspectus  of  the  Medical  Sciences. 

A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anat- 
omy, Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
By  HENRY  HARTSHORNS,  A.  M.,  M.  D.,  LL.  D.,  lately  Professor  of  Hygiene  in  the  Uni- 
versity of  Pennsylvania,  Second  edition,  thoroughly  revised  and  greatly  improved.  In 
one  large  royal  12mo.  vol.  of  1028  pages,  with  477  illus.  Cloth,  $4.25;  leather,  $5.00. 


PARRY  ON  EXTRA-UTERINE  PREGNANCY: 
Its  Clinical  History,  Diagnosis,  Prognosis  aud 
Treatment.  Octavo,  272  pages.  Cloth,  $2.50. 

CONDIE'S    PRACTICAL    TREATISE    ON    THE 


Physician  to  the  Philadelphia  Hospital,  etc. 
Third  edition,  thoroughly  revised,  and  greatly 
enlarged.  In  one  12mo.  volume  of  816  pages, 
with  370  illustrations.  Cloth,  $3.25;  leather,  $3.75. 


DISEASES  OF  CHILDREN.  Sixth  edition,  re-  i  WEST  ON  SOME  DISORDERS  OF  THE  NERV- 
vised  and  augmented.  In  one  octavo  volume  of  J  OUS  SYSTEM  IN  CHILDHOOD.  In  one  small 
779  Datres  Cloth,  $5.25 ;  leather,  $G.25.  12mo.  volume  of  127  pages.  Cloth,  $1.00. 

LUDLOWS  MANUAL  OF  EXAMINATIONS.  A  '  WINCKEL'S  COMPLETE  TREATISE  ON  THE 
Manual  of  Examinations  upon  Anatomy,  Physi-  j  PATHOLOGY  AND  TREATMENT  OF  CHILD- 
ology,  Surgery,  Practice  of  Medicine,  Obstetrics,  i  BED.  For  Students  and  Practitioners.  Trans- 
Materia  Medica,  Chemistry,  Pharmacy  and  !  lated  from  the  second  German  edition,  by  J.  R. 
Therapeutics.  To  which  is  added  a  Medical  CHABWICK,  M.  D.  Octavo  484  pages.  Cloth,  $4.00. 
Formulary.  By  J.  L.  LUDLOW,  M.  D.,  Consulting 


lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


fledical  Jurisprudence,  Historical. 


31 


Taylor's  Medical  Jurisprudence.— Twelfth  Edition. 

A  Manual  of  Medical  Jurisprudence.  By  ALFRED  S.  TAYLOR,  M.  D., 
Lecturer  on  Med.  Jurisprudence  and  Chemistry  in  Guy's  Hosp.,  London.  New  American 
from  the  12th  English  edition.  Thoroughly  revised  by  CLARK  BELL,  Esq.,  of  the  New 
York  Bar.  In  one  octavo  volume  of  787  pages,  with  56  illus.  Cloth,  $4.50;  leather,  $5.50. 
This  is  a  complete  revision  of  all  former  Ameri-  into  the  criminal  courts.  The  editor  has  given  to 
can  and  English  editions  of  this  standard  book,  two  professions  a  reference-book  to  be  relied  upon. 
This  edition  contains  a  large  amount  of  entirely  — The  American  Journal  of  the  Medical  Sciences. 
new  matter,  many  portions  of  the  book  having  No  library  is  complete  without  Taylor's  Medical 
been  rewritten  by  the  editor.  Many  cases  and  j  Jurisprudence,  as  its  authority  is  accepted  and  un- 
authorities  have  been  cited,  and  the  citations  questioned  by  the  courts.— Buffalo  Medical  and 
brought  down  to  the  latest  date.  The  book  has  Surgical  Journal. 

long  been  a  standard  treatise  on  the  subject  of!  There  is  no  other  work  upon  the  subject  which 
medical  jurisprudence,  and  haa  gone  through  i  has  been  so  uniformly  recognized  or  so  widely 
many  editions— twelve  English  and  eleven  Ameri-  quoted  and  followed  by  courts  In  England  and  this 
can.  Mr.  Clark  Bell  has  enlarged  and  improved  country.  This  eleventh  American  edition  is  fully 
what  already  seemed  complete,  by  bringing  his  abreast  with  the  most  recent  thought  and  knowl- 
many  citations  of  cases  down  to  date  to  meet  the 
present  law  ;  and  by  adding  much  new  matter  he 
has  furnished  the  medical  profession  and  the  bar 
with  a  valuable  book  of  reference,  one  to  be  relied 
upon  in  daily  practice,  and  quite  up  to  the  present 
needs,  owing  to  its  exhaustive  character.  It 
would  seem  that  the  book  is  indispensable  to  the 
Jibrary  of  both  physician  and  lawyer,  and  particu- 
larly the  legal  practitioner  whose  duties  take  him 


abreast  with  the  most  recent  thought  and  kn,,,, . 
edge.  On  the  basis  of  his  own  researches,  of  the 
investigations  of  scientists  throughout  the  world, 
and  of  the  decisions  of  our  own  courts,  Mr.  Bell 
has  incorporated  in  it  a  wealth  of  practical  sug- 
gestion and  instructive  illustration  which  cannot 
fail  to  strengthen  the  hold  it  has  so  long  had 
upon  the  profession. —  The  Criminal  Law  Magazine 


and  Reporter. 


By  the  Same  Author. 

Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.    Third 
American,  from  the  third  and  revised  English  edition.     In  one  large  octavo  volume  of  788 
Cloth,  $5.50 ;  leather,  $6.50. 


Lea's  Superstition  and  Force.— New  Edition.    Just  Ready. 

Superstition  and  Force:  Essays  on  The  Wager  of  Law,  The 
Wager  of  Battle,  The  Ordeal  and  Torture.  By  HENRY  CHARLES  LEA, 
LL.  D.,  New  (4th)  edition,  revised  and  enlarged.  Koyal  12mo.,  629  pages.  Cloth,  $2.75. 


Both  abroad  and  at  home  the  work  has  been 
accepted  as  a  standard  authority,  and  the  author 
has  endeavored  by  a  complete  revision  and  con- 
siderable additions  to  render  it  more  worthy  of 
the  universal  favor  which  has  carried  it  to  a 
fourth  edition.  The  style  is  severe  and  simple. 
and  yet  delights  with  its  elegance  and  reserved 
strength.  Tne  known  erudition  and  fidelity  of 
the  author  are  guarantees  that  all  possible  origi- 
nal sources  of  information  have  been  not  only 
consulted  but  exhausted.  The  subject  matter  is 


handled  in  such  an  able  and  philosophic  man- 
ner that  to  read  and  study  it  is  a  step  toward 
liberal  education.  It  is  a  comfort  to  read  a  book 
that  is  so  thorough,  well  conceived  and  well  done. 
We  should  like  to  see  it  made  a  text-book  in  our 
law  schools  and  prescribed  course  for  admission 
to  the  bar. — Legal  Intelligencer. 

A  work  as  remarkable  for  the  wealth  of  histori- 
cal material  treated  as  for  the  masterly  style  of 
the  exposition.—  London  Saturday  Review. 


By  the  same  Author. 

Chapters  from  the  Religious  History  of  Spain.— In  one  12mo.  volume 
of  522  pages.     Cloth  $2.50. 


The  width,  depth  and  thoroughness  of  research 
which  have  earned  Dr.  Lea  a  high  European  place 
as  the  ablest  historian  the  Inquisition  haa  yet 
found  are  here  applied  to  some  side-issues  of  that 
great  subject.  We  have  only  to  say  of  this  volume 


that  it  worthily  complements  the  author's  earlier 
studies  in  ecclesiastical  history.  His  extensive 
and  minute  learning,  much  of  it  from  inedited 
manuscripts  in  Mexico,  appears  on  every  page.— 
London  Antiquary. 


In  one  8vo.  volume  of  219 


By  the  same  Author. 

The  Formulary  of  the  Papal  Penitentiary, 
pages,  with  a  frontispiece.     Cloth,  $2.50.     Just  Ready. 

By  the  Same  Author. 

Studies  in  Church  History.  The  Rise  of  the  Temporal  Power— Ben- 
efit of  Clergy— Excommunication— The  Early  Church  and  Slavery,  bec- 
ond  and  revised  edition.  In  one  royal  octavo  volume  of  605  pages.  Cloth,  $2.50. 


The  author  is  preeminently  a  scholar;  he  takes 
np  every  topic  allied  with  the  leading  theme  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  of  information 
compressed  into  the  book  is  extraordinary,  and 
the  profuse  citation  of  authorities  and  references 


makes  the  work  particularly  valuable  to  the  student 
who  desires  an  exhaustire  review  from  original 
sources.  In  no  other  single  volume  is  the  develop- 
ment of  the  primitive  church  traced  with  so  much 
clearness  and  with  so  definite  a  perception  of 
complex  or  conflicting  forces.— Boston  TraveUtr. 


By  the  Same  Author. 

An   Historical   Sketch  of  Sacerdotal   Celibacy   in   the    Christian 
Church.     Second  edition,  enlarged.    In  one  octavo  volume  of  685  pages.    <     >th,  »4.oU. 


This  subject  has  recently  been  treated  with  very 
great  learning  and  with  admirable  impartiality  by 

? _..A! TliT_      !!„„,.,.   r*     T  .AO     in    h  iu    M1  «. 


author 


more  lighten  the  moral  condition  of  the  Middle 
Ages,  and  none  which  is  more  fitted  to  dispel  the 


:  LeaVTn'hiR  "tfw-    gross'  illusions  concerning  that  period  wUcfe  posl- 
raowc  Ms  certainly  one    five  writers  and  ^tW^O 
of  fhe  most  valuable  works  that  America  has  pro-  |  school  have  C™»P  Jedh^''u*t 
duced.    Since  the  great  history  of  Dean  Milman,    of  European  Morals,  Chap.  V. 
I  know  no  work  in  English  which  has  thrown 


_ 

Lea  Brothers  &  Co.,  Publishers,  706,  708  &  710  Sansom  Street,  Philadelphia. 


Index  to  Catalogue  of    Medical  Publications 


-OF- 


LEA  BROTHERS  &  Co., 

706,  708  A.  71O  SANSOM  STREET,  PHILADELPHIA. 


Abbott's  Bacteriology    ....  19 

Allen's  anatomy 6 

American  Journal  of  the  Med- 
ical Sciences 2 

American  Systems  of  Gynecol- 

ogy  and  Obstetrics 27 

American  System  of  Practical 

Medicine 14 

American  System  of  Dentistry  24 
American  Text-Books  of  Dent- 
istry    24 

Ashhurst's  Surgery 20 

Ashwell  on  Diseases  of  Women  28 

Attfield's  Chemistry 9 

Ball  on  the  Rectum  and  Anus  21,30 
Barnes'  System  of  Obstetric 

Medicine  and  Surgery     ...  29 

Bartholow  on  Cholera    ....  16 

Bartholow  on  Electricity      .    .  16 

Basham  on  Renal  Diseases    .    .  23 
Bell's    Comparative   Anatomy 

and  Physiology 7,  30 

Bellamy's  Surgical  Anatomy    .  6 

Berry  on  the  Eye 23 

Billings'  National  Medical  Dic- 
tionary    4 

Black  on  the  Urine 24 

Blandford  on  Insanity   ....  18 

Bloxam's  Chemistry 9 

Broadbent  on  the  Pulse.     .    .  15,  30 

Browne  on  Koch's  Remedy  .    .  17 
Browne  on  the  Throat,  Nose 

and  Ear 17 

Bruce's    Materia   Medica   and 

Therapeutics 13,  30 

Brunton's  Materia  Medica  and 

Therapeutics 18 

Bryant's  Practice  of  Surgery     .  21 
Bumstead  and  Taylor  on  Vene- 
real Diseases     See  Taylor  .    .  25 

Burnett  on  the  Ear 24 

Butlin  on  the  Tongue     .     ..  20,30 
Carpenter  on  the  Use  and  Abuse 

of  Alcohol 7 

Carpenter's  Human  Physiology  7 
Carter  &  Frost's  Ophthalmic 

Surgery 23,30 

Caspari's  Pharmacy 10 

Chambers  on  Diet  and  Regimen  16 

Chapman's  Human  Physiology  8 
C  h  a  r  1  e  s'    Physiological    and 

Pathological  <  'hen.  istry  ...  10 
C  h  e  y  n  e  on  Wounds,   Ulcers 

and  Abcessess 22 

Churchill  on  Puerperal  Fever  .  29 
Clarke  and  Lockwood's  Dissec- 
tors' Manual 6, 30 

Cleland's  Dissector 6 

Clouston  on  Insanity      ...    .17 

Clowes'  Practical  Chemistry     .  8 

Coats'  Pathology 19 

Cohen's  Applied  Therapeutics  32 

Coleman's  Dental  Surgery     .    .  24 

Condie  on  Diseases  of  Children  30 

Cornil  on  Syphilis        25 

Culver  &  Hayden  on  Venereal 

Diseases 25 

Dalton  on  the  Circulation      .    .  7 

Dalton's  Human  Physiology    .  8 

Davenport  on  Dis  of  Women    .  28 

Davis'  Clinical  Lectures    ...  14 

Davis'  Obstetrics 29 

Dennis'  System  of  Surgery    .    .  22 

Dercum  on  Nervous  Diseases    .  18 

Dispensatory,  The  National .    .  11 

Draper's  Medical  Physics  ...  7 

Drmtt's  Modern  Surgery   ...  20 

Duane's  Medical  Dictionary  .    .  3 

Duncan  on  Diseases  of  Women  27 

Dungllson's  Medical  Dictionary  4 
Edes'  Materia  Medica  and 

Therapeutics 12 

Edis  on  Diseases  of  Women  .    .  27 

Ellis'  Anatomy 7 

Emmet's  Gynaecology    ....  27 

Erichsen's  Surgery 21 

Farquharson's  Therapeutics 

and  Maleria  Medica    ....  13 
Field's  Manual  of  Diseases  of 

the  Ear 24 

Flint  on  Auscultation  and  Per- 
cussion   15 

Flint  on  Phthisis 13 

Flint  on  Respiratory  Organs     .  1-1 

Flint  on  the  Heart 13 

Flint's  Essays 13 

Flint's  Practice  of  Medicine  .    .  13 
Folsom's  Laws  of  U.  S.  on  Cus- 
tody of  Insane 17 

Foster's  Physiology    ....  8 
Fotnergill's  Handbook   of 

Treatment 15 

Fownes'  Elementary  Chemistry  9 
Fox  on  Diseases  of  the  Skin  .    .  25 
Frankland    and    Japp's   Inor- 
ganic Chemistry 8 


Puller  on  the  Lungs  and  Air 

Passages 17 

Fuller  on  Male  Sexual  Disorders  25 
Gant's  Student's  Surgery  .  .  20 
Gibbes'  Practical  Pathology  .  19 
Gould's  Surgical  Diagnosis  .  20,  30 
Gray  on  Nervous  and  Mental 

Diseases 18 

Gray's  Anatomy 5 

Greene's  Medical  Chemistry  .  9 
Green's  Pathology  and  Morbid 

Anatomy      19 

Gross  on  Impotence  and  Sterility  25 
Gross  on  Urinary  Organs  ...    25 
Habershon  on  the  Abdomen     .    14 
Hamilton  onFractures  and  Dis- 
locations    22 

Hamilton  on  Nervous  Diseases  18 
Hardaway  on  the  Skin  ...  25 
Hare's  Practical  Therapeutics  .  12 
Hare's  System  of  Practical 

Therapeutics 12 

Hartshorne's  Anatomy   and 

Physiology 6 

Hartshorne  s  Conspectus  of  the 

Medical  Sciences      .    ,    .    .    .    30 
Hartshorne's  Essentials  of 

Medicine 13 

Hayem's  Physical  and  Natural 

Therapeutics 16 

Herman's  Midwifery     ....    30 
Hermann's  Experimental  Phar- 
macology   1! 

Herrick's  Diagnosis 16 

Hill  on  Syphilis 25 

HI  liter's  Handbook  of  Skin 

Diseases 25 

Hirst   &    Piersol    on     Human 

Monstrosities 6 

Hoblyn's  Medical  Dictionary    .     5 

Hodge  on  Women 27 

Hoffmann  and  Power's  Chem- 
ical Analysis 10 

Holden's  Landmarks  ....  6 
Holland's  Medical  Notes  and 

Reflections    .    .    , 14 

Holmes'  Surgery    ......    20 

Holmes'  System  of  Surgery  .  .  1.0 
Homer's  Anatomy  and  Histology  6 

Hudson  on  Fever 13 

Hutchinson  on  Syphilis     .    .25,30 

Hyde  on  the  Skin 26 

Jackson  on  the  Skin  .  .  .  26 
Jamieson  on  the  Skin  ....  26 
Jones  on  Nervous  Disorders  .  18 
Juler's  Ophthalmic  Science  and 

Practice 23 

King's  Manual  of  Obstetrics  .    .    29 

Klein's  Histology 18,  30 

Landis  on  Labor 29 

La  Roche  on  Pneumonia,  Mala- 
ria, eic.      .        .    .        ....    17 

La  Roche  on  Yellow  Fever   .    .    13 
Laurence  and  Moon's  Ophthal- 
mic Surgery 23 

Lawson  on  the  Eye 23 

Lea's  Chapters  from  Religious 

History  of  Spain 31 

Lea's  Formulary  of  the  Papal 

Penitentiary 31 

Lea's  Sacerdotal  Celibacy  ...    31 
Lea's  Studies  in  Church  History  31  ; 
Lea's  Superstition  and  Force    .    31  i 

Lee  on  Syphilis 25  i 

Lehmann  s  Chemical  Physiology  7 
Leishman's  Midwifery   .    .    .    .29 
Lucas  on  the  Urethra     ....    30 
Ludlow's  Manual  of  Examina- 
tions   30 

Luff's  Manual  of  Chemistry  .  9,  30 
Lyman's  Practice  of  Medicine  14 

Lyons  on  Fever 13  : 

Maisch's  Organic  Materia  Medica  12 
Mackenzie  on  Nose  and  Throat   17 
Marsh  on  the  Joints       .    .    .    20,30) 
May  on  Diseases  of  Women   .    .    28  ! 

Medical  News 1  j 

Medical  News  Physicians'  Ledger  2 
Medical  News  Visiting  List  .  .  2  ; 
Miller's  Practice  of  Surgery  .  .  20  j 
Miller's  Principles  of  Surgery  20  , 
Mitchell  on  Nerve  Injuries  .  •  18  , 
Morris  on  the  Kidney  .  .  .  23,  30 

Morris  on  the  Skin 26  i 

Musser's  Medical  Diagnosis .    .    15  i 
National  Dispensatory  ....    11  ! 
National  Medical  Dictionary    .     4  j 
Nettleship  on  the  Eye   .        .    .    23  • 
Norris  and  Oliver  on  the  Eye    .    23  | 
Owen  on  Diseases  of  Children  .    30 
Parry  on  Extra-Uterine  Preg- 
nancy      30  j 

Parvin's  Obstetrics lit 

Pavy  on  Digestive  Disorders  .  16 
Payne's  General  Pathology  .  .  19 
Pepper's  Forensic  Medicine  .  .  30 


Pepper's  Surgical  Pathology  18,  30 
Pepper's  System  of  Medicine  .  14 
Pick  on  Fractures  and  Disloca- 

tions    ........    22,  30 

Pirrie's  System  of  Surgery  .  20 
Playfair  on  Nerve  Prostration 

and  Hysteria    .......    17 

Playfair's  Midwifery  .....    29 

Politzer  on  the  Ear      .    .        .    .    24 

Power's  Human  Physiology  .  7,  30 
Purdy  on  Bright's  Disease  and 

Allied  Affections      .....    24 

Pye-Smith  on  the  Skin     ...    26 
Quiz  Series   ........     3 

Ralfe's  Clinical  Chemistry    .    10,  30 
Ramsbotham  on  Parturition     .    29 
Reichert's  Physiology     ....      7 

Remsen's  Theoretical  Chemistry  10 
Reynolds'  System  of  Medicine  .  14 
' 


Richardson's  Preventive  Med.  16 

Roberts  on  Urinary  Diseases     .  24 

Roberts'  Compend  of  Anatomy  7 

]  Roberts'  Surgery     ......  20 

Robertson's  Physiological  Phys- 
]     ics  ...........    7,30 

;  Ross  on  Nervous  Diseases  .  .  18 
Savage  on  Insanity,  including 

Hysteria  ........     18,  30 

!  Schafer's  Histology    .    .        .    .  18 

;  Schofleld's  Physiology    ....  8 

Schreiber  on  Massage     ....  16 

Seller  on  the  Throat,  Nose  and  »» 

Naso-Pharyrcr      ......  17 

Senn's  Surgical  Bacteriology     .  19 

Series  of  Clinical  Manuals      .    .  30 

Simon's  Manual  of  Chemistry  9 

Slade  on  Diphtheria   .....  17 

Smith  (Edw.)  on  Consumption  17 

Smith  (J.  Lewis)  on  Children    .  30 

Smith's  Operative  Surgery     .    .  21 

Stille  on  Cholera     ......  16 

Stillfi  &  Maisch's  National  Dis- 

pensatory     .......  11 

Still^'s  Therapeutics  and  Mate- 

ria Medica     ........  12 

1  Stimson  on  Fractures  and  Dis- 

locations   .........  22 

Stimson's  Operative  Surgery     .  22 

Students'  Quiz  Series  .....  3 

Students'  Series  of  Manuals  .    .  30 

Sturges'  Clinical  Medicine  .  .  14 
Sutton  on  the  Ovaries  and  Fal- 

lopian Tubes     .......  28 

Sutton  on  Tumors   ......  28 

Tait's  Diseases  of  Women  and 

Abdominal  Surgery    ....  27 
Tanner  on  Signs  and  Diseases 

of  Pregnancy    .......  29 

Tanner's    Manual   of    Clinical 

Medicine   .........  14 

Taylor's  Atlas  of  Venereal  and 

Skin  Dieases     .......  26 

Taylor's  Index  of  Medicine  .    .  15 

Taylor  on  Poisons  ......  31 

Taylor  on  Venereal  Diseases     .  25 

Taylor's  Medical  Jurisprudence  31 

Thomas  &  Munde  on  Women   .  28 

Thompson  on  Stricture  .    .    .    .  2i 

Thompson  on  Urinary  Organs  .  21 

Todd  on  Acute  Diseases  ...  14 
Treves'  Manual  of  Surgery  .21,30 
Treves  on  Intestinal  Obstruc- 

tion ..........    21,30 

Treves'  Operative  Surgery  .  .  21 
Treves'  Student's  Handbook  of 

Surgical  Operations     .    .    .    ,  21 
Treves'  Surgical  Applied  Anat- 

omy   ..........    6,  30 

Tuke  on  the  Influence  of  the 

Mind  on  the  Body    .....  17 
Vaughan  &  Novy  on  Ptomaines 

and  Leucomaineu     .....  10 

Visiting  List,  The  Medical  News  2 

Walshe  on  the  Heart  .....  14 

Watson's  Practice  of  Physic  .    .  14 

Wells  on  the  Eye    ......  23 

West  on  Diseases  of  Women  .  27 
West  on  Nervous  Disorders  in 

Childhood     ........  30 

Wharton's  Minor  Surgery  and 

Bandaging    .......  21 

Whitla's   Dictionary  of  Treat- 

ment     ..........  15 

Williams  on  Consumption  .  .  17 
Wilson's  Handbook  of  Cutane- 

ous Medicine    .......  26 

Wilson's  Human  Anatomy  .  .  6 
Winckel  on  Pathology  and 

Treatment  of  Childbed    ...  30 

WOhler's  Organic  Chemistry  .  7 
Year-Books  of  Treatment  for 

'86.  '87.  '91,  'S2,  '93,  '95  .....  I'. 

Yeo's  Medical  Treatment  ...  16 
Yeo  on  Food  in  Health  and 

Disease          .    ......  16,30 

Young's  Orthopedic  Surgery    .  20 


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